^Atfnmtt  ICtbrarg 


^  I 


LATERAL  CURVATURE  OF  THE  SPINE 

AND 

ROUND  SHOULDERS 

LOVETT 


LATERAL  CURVATURE  OF 
THE  SPINE 

AND 

ROUND  SHOULDERS 


BY 

ROBERT  W.  LOVETT,  M.  D. 

BOSTON 

JOHN    B.  AND  BUCKMINSTER   BROWN  PROFESSOR  OF  ORTHOPEDIC   SURGERY,  HARVARD  MEDICAL 

school;   SURGEON  TO  THE    CHILDREN'S    HOSPITAL,    BOSTON;    SURGEON-IN-CHIEF   TO  THE 

MASSACHUSETTS    HOSPITAL  SCHOOL,    CANTON;   CONSULTING   ORTHOPEDIC  SURGEON  TO 

THE   BOSTON   DISPENSARY;   MEMBER  OF  THE  AMERICAN  ORTHOPEDIC  ASSOCIATION; 

CORRESPONDING  MEMBER   OF    THE  ROYAL  SOCIETY  OF   PHYSICIANS,  BUDAPEST; 

KORRESPONDIERENDES    MITGLIED    DER     DEUTSCHEN     GESELLSCHAFT     FUR 

ORTHOPADISCHE     CHIRURGIE,     SOCIO     DELLA     SOCIETA    ITALIANA     DI 

ORTOPEDIA 


THIRD  EDITION,  REVISED  AND  ENLARGED 
WITH  180  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

1012  WALNUT   STREET 


Copyright,  1916,  by  P.  Blakiston's  Son  &  Co. 


THE  MAPLE  PRESS  YORK  PA 


TO 

ROBERT  JONES 

LIVERPOOL 

A  GREAT  SURGEON  AND  AN  OLD  FRIEND 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/lateralcurvaturOOIove 


PREFACE  TO  THE  THIRD  EDITION 


In  the  three  years  and  a  half  since  the  second  edition  of  this  book 
was  published  there  has  been  much  discussion  of  the  question  of  the 
treatment  of  scoliosis  by  forcible  correction,  and  a  greatly  increased 
interest  has  been  awakened  in  the  matter.  In  191 1  a  modification 
of  former  methods  of  forcible  correction  was  advocated,  and  for  this 
modification  was  claimed  a  degree  of  effectiveness  hitherto  quite 
unknown  and  not  in  accord  with  our  pathological  knowledge. 
The  method  thus  advocated  was  enthusiastically  accepted  and 
loudly  acclaimed  by  many  competent  men.  But  in  the  last  year 
or  two  a  reaction  has  set  in,  and  much  unfavorable  criticism  of  the 
method  has  been  published.  Under  these  circumstances  I  have 
fallen  back  on  my  own  personal  experience,  and  have  published 
certain  well-recorded  cases  showing  what  I  have  personally  been  able 
to  accomplish  by  forcible  correction.  In  addition  to  this  I  have 
stated  what  I  believe  to  be  the  status  of  the  matter  at  present,  a 
status  still  unsettled.  Apparently  the  time  has  come  when  a  serious 
analysis  of  the  results  by  means  of  roentgenograms  will  be  required 
to  place  the  matter  on  a  convincing  basis.  Assertions  and  opinions 
have  too  long  prevailed  in  scoliosis,  and  tangible  facts  are  now  re- 
quired. I  have  rewritten  a  large  part  of  the  section  on  treatment, 
and  I  have  revised  extensively  other  parts  of  the  book,  condensing 
where  I  could  and  expanding  where  it  seemed  necessary.  A  chapter 
on  the  history  of  scoliosis  has  been  added,  because  there  seemed  to  be 
nothing  in  English  on  the  subject.  I  have  endeavored  to  reclassify 
and  rearrange  certain  parts  of  the  book  in  order  to  present  with 
greater  clearness  certain  phases  of  this  complicated  affection,  because 
consideration  of  the  matter  has  in  the  past  tended  toward  complexity, 
and  it  has  seemed  to  me  that  a  clear  statement  of  essential  points 
was  desirable  in  a  book  ijitended  largely  for  use  as  a  text-book. 

Robert  W.  Lovett. 


PREFACE  TO  FIRST  EDITION 


The  successful  treatment  of  lateral  curvature  of  the  spine  cannot  in 
the  past  be  counted  as  one  of  the  achievements  of  orthopedic  surgery. 
The  affection  is  not  only  intrinsically  resistant  to  treatment,  but  the 
therapeutic  measures  employed  have  been  on  the  whole  largely 
empirical  and  have  not  been  sufficiently  correlated  to  its  pathology 
and  to  the  mechanism  by  which  it  is  caused.  In  the  last  ten  years, 
however,  a  good  deal  of  progress  has  been  made  along  new  and  prom- 
ising lines,  by  means  of  experimental  and  clinical  work,  the  records 
of  which  lie  scattered  through  later  medical  literature.  In  the  follow- 
ing pages  I  have  attempted  to  bring  together  this  literature  and  to 
add  my  own  personal  views  and  experience,  in  the  hope  of  presenting 
the  subject  in  English  in  a  modern  light  and  to  call  attention  to  the 
prospect  offered  of  obtaining  better  results.  That  such  a  book  is 
needed  I  have  been  led  to  infer  from  many  inquiries  in  connection 
with,  this  subject  by  physicians,  medical  students,  and  teachers  of 
physical  training.  If  I  have  devoted  too  large  a  part  of  the  book  to 
the  question  of  treatment  it  is  because  of  the  scant  attention  paid  to 
that  part  of  the  subject  in  most  books  dealing  with  deformities. 

The  anatomical  part  of  the  work  is  from  the  Anatomical  Depart- 
ment of  Harvard  University,  and  much  of  the  clinical  work  is  from 
the  Scoliosis  CHnic  of  the  Children's  Hospital,  Boston. 

It  is  impossible  to  acknowledge  my  indebtedness  individually  to 
those  of  my  colleagues  and  others  who  have  helped  me  by  contribut- 
ing material  and  other  assistance.  I  should,  however,  express  my 
obligation  to  Professor  Thomas  D  wight  for  his  advice  given  in  con- 
nection with  the  anatomical  part  of  my  work,  for  the  liberal  supply 
of  anatomical  material  with  which  he  has  provided  me,  and  for 
criticising  my  chapter  on  Anatomy.  To  Miss  Amy  Morris  Homans, 
Director  of  the  Boston  Normal  School  of  Gymnastics,  I  wish  to  ex- 
press my  indebtedness  for  assistance  given  in  many  ways;  and  to  my 
assistants,  Fraiilein  Helene  Seltmann  and  Miss  W.  G.  Wright,  for 
great  help  in  preparing  the  list  of  exercises. 

I  have  used  freely  the  chapters  on  Pathology  and  Occurrence  in  the 
admirable  article  on  Scoliosis  by  Schulthess  of  Zurich,  recently  pub- 
lished in  Joachimsthal's  "Handbuch  der  Orthopadischen  Chirurgie." 

Robert  W.  Lovett. 
Boston. 

ix 


TABLE  OF  CONTENTS 


Chapter  Page 

I.  History  of  Scoliosis i 

II.  The  Anatomy  of  the  Vertebral   Column  and  the 

Thorax 8 

HI.  The  Movements  of  the  Spine 29 

IV.  The  Mechanism  of  Scoliosis 43 

V.  Description  and  Symptoms 51 

VI.  Examination  and  Record  of  Scoliosis 71 

VIL  Pathology .  83 

VIII.  Etiology 97 

IX.  Occurrence m 

X.  Relation  of  Scoliosis  to  School  Life 117 

XI.  Diagnosis 124 

XII.  Prognosis 127 

XIII.  Treatment 129 

XIV.  Faulty  Attitude 191 

Index 211 


LATERAL  CURVATURE  OF  THE  SPINE 
AND  ROUND  SHOULDERS 


CHAPTER  I 
THE  HISTORY  OF  SCOLIOSIS ^ 

To  write  the  history  of  scoliosis  one  must  start  with  the  begin- 
nings of  medicine  and  follow  down  through  some  2500  years  the 
course  of  an  affection  for  many  centuries  classed  with  other  cur- 
vatures of  the  spine,  and  considered,  as  they  were  considered, 
due  to  dislocation  of  the  vertebrae.  One  finds  in  this,  as  in  most 
affections  long  recognized,  that  time  brings  about  its  identification 
as  an  entity,  after  which  it  gradually  becomes  separated  from 
similar  affections  and  is  discussed  by  itself. 

The  term  "scoliosis"  dates  much  farther  back  than  the  recogni- 
tion of  the  affection  itself.  ckoKloo:,  from  which  scoliosis  is  derived, 
is  a  Homeric  word  meaning  to  bend  or  twist,  and  the  term  (tkoXlcosls 
was  first  used  by  Hippocrates,  who  lived  four  centuries  before  the 
beginning  of  the  Christian  era.  His  use  of  the  word  apparently  was 
to  designate  a  lateral  form  of  the  spinal  curve  supposed  to  be  due  to 
dislocation,  the  forward  curve  being  called  lordosis  and  the  back- 
ward curve  kyphosis.  There  were  two  other  words  in  use  at  this 
time  which  have  dropped  out,  and  which  are  of  no  significance. 

Although  the  name  scoliosis  was  given  by  Hippocrates,  a  very 
short  extract  from  his  works  will  show  that  he  had  little  or  no  idea  of 
what  the  condition  was.  After  a  description  of  posterior  curvature 
of  the  spine,  which  is  fairly  accurate  in  a  very  rough  way,  he  goes 
on: — "In  some  cases  the  curvature  of  the  spine  is  lateral,  that  is  to 
say,  either  to  the  one  side  or  to  the  other,  and  most  of  such  cases  are 
connected  with  tubercles  (abscesses?)  within  the  spine,  and  in  some 
the  position  in  which  they  had  been  accustomed  to  lie  cooperates 

with  the  disease but  these  will  be  treated 

of  among  the  common  affections  of  the  lungs." 

^ "  Geschicte  und  Behandlung  der  seitlichen  Ruckgratsverkriimmung," 
Strassburg,  1885. 

Chlumsky:     "  Prispezky  k  Dejinam  Skoliosy,"  Prag,  1910 


2  THE   HISTORY    OF   SCOLIOSIS 

"Lateral  curvatures  also  occur,  the  approximate  cause  of  which 
is  the  attitudes  in  which  these  people  lie.  These  cases  have  the 
prognostics  accordingly," 

Yet  Hippocrates  gave  a  very  clear  description  of  club-foot,  which 
was  well  recognized  by  him,  and  although  the  spHnts  advised  seem 
rather  inefficient,  the  treatment  by  moulding  and  retention  was 
advocated.  Patients  with  spinal  curves,  however,  were  tied  by 
the  legs  to  a  ladder,  and  the  ladder  raised  and  then  dropped  to  the 
ground,  striking  on  one  end,  thus  tending  to  straighten  the  spine,  or 
such  patients  were  put  into  an  apparatus  to  make  extension  and 
pressure  on  the  prominence.  He  adds  as  a  further  refinement  of  his 
treatment: — "It  is  also  safe  for  a  person  to  sit  upon  the  hump  while 
extension  is  being  made,  and  raising  himself  to  let  himself  fall  down 
again  upon  the  patient."  He  also  suggests  putting  one  foot  on  the 
hump  or  using  a  long  wooden  lever,  but  one  finds  no  mention  of  any 
attempt  at  retention,  and  the  reason  for  this  is  that  all  the  treat- 
ment was  based  on  the  supposition  that  the  affection  was  due  to  a 
dislocation,  which  demanded  reduction  only. 

For  about  2000  years  after  Hippocrates,  scoliosis  attracted  little 
attention  and  no  advance  was  made.  Paul  of  Aegina,  650  A.  D., 
suggested  bandaging  to  wooden  strips  in  cases  of  curvature  of  all 
varieties,  and  Albukasis  500  years  later  announced  that  "no  one 
could  cure  curvature  to  the  side." 

And  so  one  comes  down  through  the  centuries  with  no  new  light 
to  the  time  of  Ambroise  Pare,  born  in  1510,  and  we  find  him  where 
we  left  Hippocrates  2000  years  before.  I  quote  from  his  writings: 
"A  dislocated  vertebra  standing  forth  and  making  a  bunch  is  termed 
in  Greek  kyphosis,  but  when  it  is  depressed  it  is  called  lordosis,  but 
when  the  same  is  luxated  to  the  right  or  left  side  it  maketh  a  scoliosis, 
which,  wresting  the  spine,  draws  it  into  the  similitude  of  the  letter  S 

Fluid  and  soft  bodies,  such  as  children,  are  very  subject 

to  generate  this  internal  cause  of  defluxion.  Thus  nurses,  while  they 
too  straitly  lace  the  breasts  and  sides  of  girls  so  to  make  them 
slender,  cause  the  breast-bone  to  cast  itself  in  forward  or  back,  or 
else  the  one  shoulder  to  be  bigger  or  fuller,  the  other  more  spare  or 
lean.  The  same  error  is  committed  if  they  la}^  children  frequently 
and  long  upon  their  sides,  then  upon  their  backs,  or  if  in  taking  them 
up  when  they  walk  they  take  them  only  by  the  feet  or  legs  and  never 
put  their  other  hand  in  their  backs,  never  so  much  as  thinking  that 
children  grow  most  toward  their  heads."  Then  follows  a  fair  ac- 
count of  the  deformity,  and  the  reduction  of  the  dislocation  is  on  the 


HISTORY  3 

same  lines  as  advocated  by  Hippocrates,  by  extension  and  pressure 
by  the  hand  or  by  lever.  He  suggested,  however,  the  use  of  a  padded 
iron  corset,  the  illustrations  of  which  are  familiar,  but  still  it  was 
always  a  dislocation  that  was  considered.  It  was  to  be  treated  by 
levers  and  great  force,  and  the  after-treatment  played  only  a  very 
small  part. 

Among  the  various  authors  of  the  next  hundred  years  one  finds 
silence  on  the  subject  in  most,  such  as  Fabricius,  Hieronymus  and 
Vesalius,  but  here  and  there  are  flashes  of  light,  mostly  fantastic 
speculations  as  to  etiology,  but  the  affection  was  frequent,  for 
Riolan,  in  1641,  stated  that  in  France  the  girls  carried  as  a  rule  the 
left  shoulder  higher  than  the  right,  and  that  one  could  hardly  find 
a  case  where  the  shoulders  were  rightly  constructed.  His  speculations 
as  to  etiology  were  much  the  same  as  those  of  the  nineteenth  century, 
namely,  the  use  of  the  right  arm  and  the  wearing  of  stiffened  corsets. 
The  first  autopsy  of  a  scoliotic  case  was  reported  in  1646  by  Fabricius 
Hildanus,  without  apparently  clearing  up  the  matter.  Glisson, 
writing  of  rickets,  which  he  named  rachitis,  in  1660,  described  the 
spinal  curves  due  to  it,  and  suggested  for  this  indiscriminate  treat- 
ment gymnastics  or  suspension,  but  Glisson's  suspension  was  from 
axillse,  head  and  hands,  by  which  the  children  were  slung  and  allowed 
to  play  in  the  air,  which  he  adds  "they  did  with  great  enjoyment." 
The  head  sling  proper  dates  from  Nuckius  in  1696,  and  was  devised 
for  the  treatment  of  wry  neck. 

From  this  time  until  the  time  of  Andre  in  1741,  one  cannot  see 
that  any  author  contributed  much  to  progress,  although  it  is  evident 
that  whalebone  corsets  were  coming  into  use  as  a  method  of  treat- 
ment, originating  with  Jungken  in  1691,  and  the  mention  of  scoliosis 
is  more  frequent  than  in  the  preceding  century,  but  never  apparently 
differentiated  clearly  from  other  curvatures. 

Andre  was  a  man  of  originality,  the  inventor  of  the  term  "ortho- 
pedic," and  he  wrote  more  fully  of  spinal  curves  than  his  predecessors. 
He  condemned  high  heels  and  blamed  them  and  bad  sitting  positions 
for  much  of  the  faulty  attitude.  Among  causes  for  spinal  curves  he 
mentioned  hemorrhoids,  which  were  so  painful  that  the  child  could 
not  sit  squarely,  and  he  called  attention  to  the  important  fact  that 
as  a  child  grew  the  clothes  must  be  made  larger.  He  suggested 
gymnastics  and  apparatus  as  a  means  of  treatment. 

Taking  it  altogether  the  middle  of  the  eighteenth  century,  that  is 
to  say,  the  time  of  the  beginning  of  the  American  Revolution,  was  a 
time  of  considerable  activity  and  some  little  progress  in  the  history 


4  THE    HISTORY    OF    SCOLIOSIS 

of  scoliosis.  Andre  was  the  first  to  group  deformities  together  and 
to  give  a  name  to  the  specialty.  His  directions  about  treatment  were 
vague,  but  he  recognized  in  bow  legs  at  least  that  the  same  means 
must  be  taken  to  straighten  them  as  were  adopted  to  straighten  the 
crooked  stem  of  a  young  tree.  He  advocated  friction  of  the  de- 
formed parts  and  their  gradual  restoration  by  manual  extension, 
pressure  and  localized  movement.  A  very  distinct  step  at  about  this 
time  was  made  by  the  classical  work  of  Percival  Pott,  who  pubUshed 
in  1779,  his  essay  on  "The  Palsy  of  the  Lower  Limbs  in  Consequence 
of  a  Curvature  of  the  Spine."  In  this  work  he  took  out  of  the  un- 
classified group  of  affections  known  as  curvatures  of  the  spine,  those 
posterior  curves  caused  by  spinal  tuberculosis.  He  stated  with 
regard  to  the  paralysis  "that  none  of  those  strange  twists  and  de- 
viations which  the  majority  of  European  women  get  in  their  shapes 
from  the  very  absurd  custom  of  dressing  them  in  stays  during  their 
infancy,  and  which  put  them  into  all  directions  but  the  right,  ever 
caused  anything  of  this  kind,  however  great  the  deformity  might 
be."  His  description  of  spinal  tuberculosis  was  so  accurate  that  it 
immediately  identified  posterior  curvature  as  a  carious  or  scrofulous 
disease  of  bone  and  not  as  a  dislocation,  and  thus  cleared  the  field 
for  the  recognition  of  scoliosis  as  an  entity. 

About  this  time  scoliosis  was  becoming  more  clearly  defined. 
Autopsies  were  being  performed,  and  it  was  being  recognized  that  it 
was  not  to  be  classed  and  treated  with  the  posterior  curvatures. 
This  came  not  only  from  the  work  of  Pott,  but  was  gradually  coming 
in  from  all  sides,  and  apparatus  of  various  kinds  began  to  be  devised. 
The  iron  cross  of  Heister,  invented  in  1 700,  began  to  be  displaced  by 
apparatus  more  of  the  modern  type,  and  the  corset  of  Maguy,  de- 
vised in  1762,  would  find  a  sale  to-day  in  the  instrument  shops;  but 
the  greatest  impetus  was  given  by  the  apparatus  of  Levacher  in 
1768,  which  consisted  of  a  whalebone  corset  to  which  was  affixed 
jury  mast  and  a  head  sling. 

Although  the  period  at  the  middle  of  the  eighteenth  century,  as 
has  been  said,  was  one  of  considerable  activity  and  progress  in  the 
development  of  scoliosis,  at  about  this  time  there  began  and  lasted 
for  over  a  hundred  years,  the  dreariest  and  most  confusing  period 
in  the  history  of  the  affection.  The  theorist  and  the  apparatus  in- 
ventor went  mad,  and  every  form  of  device  appeared.  Braces  and 
corsets  infinitely  complicated,  worse  than  useless,  appeared  by  the 
dozen.  Beds  especially  constructed,  chairs,  slings,  swathes,  belts, 
levers  and  the  like,  all  found  their  advocates,  and  theories  as  to  the 


HISTORY  5 

causation  also  ran  riot,  but  on  the  whole  the  invention  and  elbaora- 
tion  of  apparatus  held  the  center  of  the  stage,  and  one  heard  but 
little  of  gymnastics. 

It  is  difficult  to  trace  the  origin  of  the  gymnastic  treatment  of 
scoliosis,  for  it  had  existed  from  an  early  time.  Even  as  early  as 
Glisson  a  system  of  gymnastics  was  clearly  formulated,  and  appar- 
ently gymnastic  treatment  was  not  at  that  time  by  any  means 
new.  Sydenham,  1624-1689,  wrote  "If  anyone  knew  of  the  values 
of  friction  and  exercise  and  could  keep  his  knowledge  secret  he 
might  easily  make  a  fortune,"  and  "Fuller's  Medicina  Gymnastica," 
published  in  1704,  was  followed  by  a  similar  work  by  Tissot  in  1781, 
and  by  Jahn  and  others,  who  worked  with  energy  to  spread  German 
gymnastics.  A  very  decided  impetus  came  from  Sweden  from  Henry 
Ling,  who  died  in  1839,  and  who  founded  a  system  of  gymnastics 
known  as  the  Ling  system  or  Swedish  movement  treatment.  An 
institute  under  the  supervision  of  the  Swedish  government  was 
established  in  Stockholm,  and  Ling  was  its  first  president.  A  paper 
advocating  gymnastic  treatment  was  published  by  Langgard  in 
1868,  and  books  and  monographs  followed  in  rapid  succession. 

Thus  toward  the  middle  of  the  nineteenth  century,  at  the  close 
of  the  hundred-year  period  which  has  been  spoken  of  as  drear}^  and 
demoralizing,  gymnastic  treatment  began  to  crowd  apparatus  treat- 
ment and  to  absorb  some  of  the  attention  previously  given  wholly 
to  mechanical  treatment.  From  this  point  gymnastic  treatment 
has  increased  in  prominence  until  it  is  fair  to  say  that  to-day  it 
constitutes  the  bulk  of  the  scoliosis  treatment  in  America. 

Shortly  after  the  middle  of  the  nineteenth  century  there  began 
what  seems  to  be  the  first  real  progress  that  had  been  made  in 
the  treatment  of  structural  scoliosis.  To  one  who  reads  the  history 
of  the  past  the  impression  is  left  that  up  to  this  time  the  etiology 
had  been  the  subject  of  a  great  deal  of  loose  and  irrational  theory, 
that  the  recognition  and  identification  of  the  affection  had  been 
delayed  for  centuries,  and  that  all  treatment  up  to  this  time  had 
been,  as  we  see  it  to-day,  ineffectual  and  comparatively  useless. 

In  1878,  Lewis  A.  Sayre  published  a  book  on  "Spinal  Disease 
and  Spinal  Curvature,"  in  which  he  advocated  their  treatment 
by  self-suspension  and  a  plaster-of-Paris  jacket.  Self-suspension 
he  credited  to  Dr.  Benjamin  Lee  of  Philadelphia  and  Prof.  Mitchell 
of  Philadelphia.  He  advocated  the  application  of  a  plaster-of- 
Paris  jacket  in  suspension,  with  the  heels  lifted  from  the  ground,  and 
he  claimed  for  them  nothing  more  than  support  in  an  improved  posi- 


6  THE   HISTORY   OF    SCOLIOSIS 

tion.  The  jackets  were  removable,  and  exercises  were  done  daily. 
The  treatment  was  too  mild  to  be  effective,  but  it  contained  appar- 
ently the  germ  of  the  modern  progress  in  the  treatment  of  the  affec- 
tion. The  use  of  plaster-of-Paris  jackets  thus  became  more  or  less 
common  in  cases  of  Pott's  disease  as  well  as  of  scoliosis,  and  the  work 
of  Calot  in  1896,  who  advocated  at  that  time  the  use  of  forcible  cor- 
rection in  the  treatment  of  Pott's  disease,  suggested  the  use  of  more 
force  than  had  been  previously  used  in  the  correction  of  lateral 
curvature.  Schanz  published,  in  1900,  an  account  of  an  efficient 
technic  for  the  application  of  jackets  in  suspension,  and  reported 
results  in  1902.  In  1901,  the  author  reported  results  and  described 
a  technic  where  the  patient  la;^  on  the  face  during  the  application, 
and  there  were  other  papers  written  at  about  this  time,  but  the 
great  impetus  to  the  treatment  by  forcible  correction  came  from 
Wullstein,  who  read  a  paper  at  the  International  Congress  in  Paris 
in  1900,  and  who  published  his  experiments,  methods  and  results 
in  1902.  He  showed  experimentally  that  bony  scoliosis  could  be 
produced  in  young  dogs  who  were  kept  for  some  months  in  a  bandage, 
inducing  a  lateral  curve  of  the  spine,  and  by  the  use  of  plaster-of- 
Paris  jackets  applied  to  the  scoliotic  patient  in  an  improved  position, 
induced  by  the  use  of  great  traction  and  lateral  pressure,  he  secured 
results  that  were  better  than  any  previously  reported.  The  work 
attracted  much  attention,  and  markedly  modified  the  whole  point  of 
view  with  regard  to  forcible  correction,  which  began  to  gather  a  body 
of  adherents  whose  number  has  steadily  increased. 

The  method  of  Wullstein  has  been  extensively  modified.  Jackets 
have  been  applied  with  the  patient  on  the  face,  on  the  side,  on  the 
back,  with  the  spine  flexed,  with  the  spine  hyperextended,  on  simple 
hammocks,  and  in  complicated  apparatus,  but  the  principle  demon- 
strated as  effective  by  Wullstein  and  carefully  elaborated  by  him 
has  not  been  modified,  namely,  crowding  the  spine  into  an  im- 
proved position  and  holding  it  there  during  as  long  a  period  as  seems 
practicable,  and  for  this  purpose  using  plaster-of-Paris. 

There  have  been  from  time  to  time  pieces  of  work  elaborated 
which  have  modified  our  point  of  view  with  regard  to  the  etiology 
of  scoliosis,  and  have  to  a  certain  extent  influenced  our  treatment. 
The  work  of  Bohm  in  1906,  called  our  attention  to  the  frequency 
of  .-.congenital  malformations  as  a  cause  of  scoliosis,  and  immediately 
transferred  many  cases  from  the  class  of  acquired  to  the  class  of 
congenital  scoliosis.  Subsequent  work  by  Bohm  and  by  others  has 
laid  stress  on  the  fact  that  the  occurrence  of  severe  scoliosis  is  prob- 


HISTORY  7 

ably  due  to  congenital  conditions  or  to  abnormalities  of  bone,  and 
that  too  much  importance  must  not  be  allowed  to  the  former  ideas 
that  severe  scoliosis  was  caused  by  assumed  bad  posture,  carrying 
burdens,  bad  school  positions,  etc. 

The  discussion  in  the  German  Orthopedic  Congress  in  1910, 
with  regard  to  school  life  as  a  cause  of  severe  scoliosis  was  most 
illuminating,  and  the  majority  of  the  writers  who  participated  were 
of  the  opinion  that  although  the  school  might  cause  a  postural 
scoliosis  it  was  very  doubtful  if  it  could  be  accepted  as  a  routine 
cause  of  severe  scoliosis. 

The  monumental  work  of  Schultess  in  the  Joachimsthal  Hand- 
buch  fiir  Orthopadische  Chirurgie  formulated,  clarified  and  illustrated 
our  knowledge  of  scoliosis. 

What  the  prevailing  treatment  of  scoliosis  is  to-day  cannot  be 
stated  in  a  few  sentences.  Some  men  advocate  one  method,  some 
another.  To  those  of  us  who  believe  that  forcible  correction  has  ac- 
complished more  than  any  other  treatment  and  will  accomplish  more 
in  the  future,  the  development  of  the  real  treatment  of  scoliosis 
dates  from  1875.  To  those  who  believe  that  the  gymnastic  treat- 
ment of  scoliosis  is  the  best,  and  that  forcible  correction  is  wrong,  the 
progress  in  the  matter  of  scoliosis  starts  with  Hippocrates  and  comes 
down  in  a  wavering  and  discouraging  line  from  that  date  until  the 
present,  with  a  better  knowledge  of  the  affection  on  the  whole,  with 
probably  some  more  effective  gymnastic  technic,  but  without  any 
very  great  advance  within  the  last  hundred  years  in  the  line  of 
efficiency. 


CHAPTER  II 

ANATOMY  OF  THE  VERTEBRAL  COLUMN  AND  THE 

THORAX 

The  spine  is  a  flexible  weight-bearing  column  made  up  of  a  series 
of  vertebrae  separated  from  each  other  by  twenty-three  intervertebral 
discs  and  connected  with  each  other  by  ligaments  and  muscles.  In 
early  life  the  vertebrae  are  thirty-three  in  number.  The  upper 
twenty-four,  remaining  separate  throughout  life,  are  distinguished  as 
true,  movable,  or  presacral  vertebrae.  In  the  adult  the  lower  nine  are 
fused  into  two  masses  to  form  the  sacrum  and  the  coccyx,  and  are  called 
the  false,  fixed,  or  immovable  vertebra.  The  spine  forms  the  central 
axis  of  the  skeleton,  situated  in  the  median  plane  of  the  body  and 
posterior  part  of  the  trunk.  By  the  term  "the  spine"  is  generally 
understood  the  part  of  the  column  above  the  sacrum. 

In  shape  the  spinal  column  is  roughly  pyramidal,  the  column  of 
vertebral  bodies  tapering  from  below  upward,  and  after  early  in- 
fancy it  shows  four  curves,  two  anterior  and  two  posterior,  in  the 
sagittal  or  median  anteroposterior  plane.  These  are  called  the 
physiological  curves,  which  will  be  discussed  later  in  the  chapter. 

The  spine  encloses  and  protects  the  spinal  cord,  and  provides,  with 
the  sacrum,  thirty-one  pairs  of  intervertebral  foramina  through 
which  the  spinal  nerves  emerge.  It  serves  by  its  intervertebral 
discs  to  diminish  the  jar  of  walking. 

The  total  length  of  the  spine  is  given  as  follows  by  different  authors: 
Cunningham,  70  to  73  cm.;  Morris,  70  cm.;  and  Krause,  72  to  75  cm. 
(along  the  curves),  which  is  45  per  cent,  of  the  body-length.  The 
relative  length  of  the  separate  regions  is  shown  in  the  following 
table: 

Dwight^ 
Cunningham'      Morns-  Beaunois  ,,  ,  _         ^ 

Cervical  region 13-14001.     12.5  cm.      10.8  cm.      13.3  cm.      12.1cm. 

Dorsal  region 27-29  cm.    27.5  cm.      27.0  cm.      28.  7  cm.      26.5  cm. 

Lumbar  region 12-15  cm.    17.5  cm.      16.8  cm.      19.9  cm.      18.7  cm. 

It  is  frequently  stated  that  the  length  of  the  spine  in  different  in- 
dividuals is  pretty  constant,  but  Dwight's  figures  show  rather  a  wide 

^  Cunningham:  "Text-book  of  Anatomy,"  Macmillan,  1902. 
^Morris:  "Human  Anatomy,"  Blakiston,  1903. 
^Dwight:  "Medical  Record,"  Sept.  8,  1894. 


ANATOMY  9 

variation.     In  fifty-six  male  spines  the  longest  was  69.8  cm.  and  the 
shortest  56.4  cm. 

In  a  straight  line,  the  column  measures  in  men  from  66  to  70  cm., 
and  in  women  from  66  to  69  cm.,  with  an  average  of  67  cm.  (Krause). 
This  height  is  approximately  40  per  cent,  of  the  total  height  of  the 


.■% 


Fig.  I. — The  Spine  Seen  from  the 
Side,  Showing  the  Physiological 
Curves. — (Warren  Museum.) 


Fig.  2. — The   Spine  Seen  from  the 
Front. — (Warren  Museum.) 


individual.     In  the  fetus  and  young  child  the  column  forms  a  greater 
proportion  of  the  body-length.     At  puberty  the  more  rapid  growth 
of  the  rest  of  the  body  overtakes  that  of  the  spine,  which  completes 
its  growth  between  the  ages  of  twenty-three  and  thirty-one  years. 
The  percentage  of  total  length  of  the  individual  occupied  by  the 


lO  ANATOMY    OF   VERTEBRAL    COLUMN    AND    THORAX 

spine  without  the  sacrum  is  given  for  dififerent  ages  by  Moser  as 
follows: 

Age  ~  Body-length  ^'"^fl^^.lh^^'^"^'^        ''bral  colutrt'o" 

'^"^'^'^  body-length 

o 50  19-2  38.4 

3 86  31.7  36.8 

5 1^2  35  30 

II 138  41  29.7 

14 152  44.  28.9 

isM 162  45  28.1 

Adult 167  57  34. 1 

The  spine  is  divided  into  three  regions  corresponding  to  the  parts 
of  the  trunk  with  which  it  is  connected:  (i)  The  cervical  region;  (2) 
the  thoracic  or  dorsal  region;  (3)  the  lumbar  region. 

The  cervical  region  comprises  the  upper  seven  vertebrae,  including 
the  atlas  and  axis;  the  thoracic,  twelve  vertebrae;  and  the  lumbar, 
five  vertebrae.  The  lower  part  of  the  spine  may  be  spoken  of  as  the 
posterior  end,  while  the  upper  part  may  be  called  the  anterior  end 
of  the  column.  The  middle  of  the  spine  is  placed  at  the  eleventh 
dorsal  vertebra. 

INTERVERTEBRAL  DISCS 

The  bodies  of  the  vertebrae,  from  the  second  cervical  to  the  sacrum, 
are  firmly  held  together  by  the  intervertebral  discs  lying  between 
them,  twenty-three  in  number.  The  discs  correspond  in  size  and 
shape  to  the  horizontal  surfaces  of  the  bodies  of  the  vertebrae  be- 
tween which  they  are  found,  but  they  project  slightly  beyond  the 
edges  of  the  vertebrae.  The  sum  of  the  heights  of  all  the  discs  is 
greatest  through  the  middle  portion,  next  largest  through  the  anterior 
borders,  and  least  through  the  posterior  borders.  Singly  the  discs 
vary  in  height  in  the  different  regions  of  the  spine.  They  are  higher 
anteriorly  in  the  cervical  and  lumbar  regions  and  posteriorly  in  the 
dorsal  region.  The  ratio  of  the  height  of  the  discs  to  the  height  of 
the  bodies  varies  according  to  different  authors.  Weber  gives  the 
ratio  of  the  average  height  of  all  the  discs  to  the  average  height  of 
all  the  vertebrae,  not  including  the  sacrum,  as  i  :  5.  According  to 
the  same  author  the  ratio  of  the  height  of  all  the  discs  through  the 
centers  to  the  height  of  the  vertebral  column,  represented  by  a 
perpendicular  from  the  highest  point  of  the  atlas  to  the  sacrum,  is 
as  1:4. 

The  influence  of  the  discs  in  the  formation  of  the  physiological 
curves  of  the  spine  is  shown  by  the  two  curves  in  Fig.  4.     Curve  (A) 


PHYSIOLOGICAL   CURVES 


II 


is  formed  by  the  bodies  and  the  discs  together,  and  curve  (B)  is  the 
result  obtained  by  placing  the  bodies  one  upon  the  other,  forming 


vmh 


Fig.  3. — Lines  Rep- 
resenting THE  Sum  of 
THE  Thickness  of  the 
Intervertebral 
Discs. — (Fick.) 

V,  At  the  front  bor- 
der; m,  in  the  middle 
of  the  disc;  h,  at  the 
posterior  border. 


a  long  curve  with  convexity  backward,  greatest 
in  the  lower  dorsal  region.  The  convexity  of 
the  thoracic  spine  is  flattened  in  the  upper  part, 
and  the  lumbar  and  cervical  physiological  curves 
almost  completely  disappear  when  the  discs  are 
removed. 

The  discs  become  smaller  and  harder  with 
age,  shrinking  to  a  greater  extent  where  they 
are  thickest  than  in  the  region  where  they  are 
thin.  For  this  reason  the  curve  of  the  spine 
in  old  age  approaches  the  long  convexity  back- 


FiG.  4. — Curves  of  the  Vertebral  Column. — {Fick.) 
A,  With  intervertebral  discs;  B,  without  intervertebral  discs. 

ward  represented  by  curve  {B),  and  the  bowed 
back  of  old  age  is  substituted  for  the  upright  at- 
titude with  a  lumbar  forward  curve  which  is 
largely  due  to  the  influence  of  intervertebral 
discs. 

The  discs  are  very  firmly  attached  to  the 
bodies  of  _  the  vertebrae,  and  are  also  attached 
to  the  anterior  and  posterior  common  ligaments 
of  the  spine.  The  intervertebral  discs  thus 
furnish  a  connecting  structure  of  great  strength 
between  each  two  vertebrae,  and  at  the  same 


12 


ANATOMY    OF  VERTEBRAL   COLUMN   AND    THORAX 


time  furnish  each  what  amounts  to  a  ball-and-socket  joint  on  ac- 
count of  the  .incompressible  fluid  pulp  in  the  center  of  each  disc 
between  each  two  vertebral  bodies,  except  of  course  the  first  two 
cervical. 

LIGAINIENTS  OF  THE  SPINE 

In  addition  to  the  connection  of  the  bodies  by  means  of  the  inter- 
vertebral discs  the  vertebrae  are  bound  together  by  ligaments  which 
serve  to  limit  movement  between  them  and  contribute  stability  and 
strength  to  the  column.     Ligaments  are  composed  of  white  fibrous 


Fig.  5. — Median  Section  of  a  Portion  of  the  Adult  Lumbar  Vertebral  Column, 
The  Right  Half  Seen  from  the  Left. — {Pick.)   \ 

tissue,  the  strongest  tissue  in  the  body,  highly  elastic,  but  non- 
extensible.  Two  of  the  spinal  ligaments,  the  ligamentum  nuchas 
and  the  subflava,  form  exceptions  to  this  statement,  being  made  up 
almost  entirely  of  yellow  fibrous  tissue. 


SACRO-ILIAC  ARTICULATION 

The  strong  joint  between  the  sacrum  and  the  ilium  through  which 
the  whole  body-weight  is  transmitted  is  a  synchondrosis.  These 
transmit  the  weight  of  the  spine  to  the  pelvis  and  thence  to  the  legs. 


SACRO-ILIAC    JOINT 


13 


They  are  ear-shaped  articular  surfaces  of  irregular  contour,  in  general 
vertical  in  direction,  containing  some  synovial  membrane  and  heavy 
ligamentous  bands.  That  they  permit  some  motion  is  well  estab- 
lished, but  this  amount  of  motion  is  small.  Klein'  found  that  25 
kg.  of  force  applied  to  the  symphysis  with  the  sacrum  fixed  produced 
a  rotation  of  the  ilia  on  the  sacrum,  which  on  the  average,  measured 
by  the  excursion  of  the 
symphysis,  was  3.9  mm.  in  man 
and  5.8  mm.  in  woman. 
Measured  at  the  sacro-iliac 
joint  this  excursion  was  about 
one-sixth  of  this  amount;  that 
is,  in  man  the  average  amount 
of  motion  in  the  sacro-iliac 
joint,  measured  at  the  pos- 
terior part  of  the  joint,  was 
about  0.6  mm.  These  joints 
are  protected  against  much 
motion  by  intra-  and  extra- 
articular ligaments  of  the 
heaviest  variety.  In  front  of 
them  lie  the  lumbosacral  cord 
and  sacral  plexus. 

THORAX 

The  thorax  is  a  bony  cage 
containing  the  principal  organs 
of  circulation  and  respiration. 
It  is  formed  by  the  thoracic 
vertebrae,  the  ribs,  the  costal 
cartilages,  and  the  sternum. 
The  ribs,  twelve  on  each  side, 
form  a  double  series  of  narrow,  curved,  flattened  bones  attached 
posteriorly  to  the  thoracic  vertebrae.  They  extend  at  first  out- 
ward, and  then  forward,  inward,  and  downward  toward  the  me- 
dian line  anteriorly.  The  seven  upper  ribs,  called  the  true,  sternal, 
or  vertebrosternal  ribs,  are  attached  directly  to  the  sternum  by 
the  costal  cartilages  anteriorly.     The  lower  five  ribs    are   called 

1  Klein:  Ztschr.  f.  Geburt.  u.  Gynak.,  1891,  xxi.  Walcher:  "Verhandl.  d. 
deutsch.  Gesellsch.  f.  Gynak.",  Bonn,  1891.  Strasser:  "Lehrbuch  der  Muskel 
und  Gelenk  Mechanik,  Berlin,"  1913.  Dieulafe  and  St.  Martin,  C.  R.:  "Assn. 
d.  Anat.",  14  Reunion  Revues,  191 2. 


Fig.  6. — Model  of  the  Spine  Showing  the 
Anatomical  Relations,  Especially  the  Dis- 
position OF  the  Soft  Parts  in  the  Lumbar 
Region. — {Warren  Museum.) 


14 


ANATOMY   OF  VERTEBRAL   COLUMN   AND    THORAX 


false  or  asternal  ribs;  the  eighth,  ninth,  and  tenth  are  distinguished 
as  vertebrochondral,  as  they  are  anteriorly  indirectly  united  to  the 
sternum  by  the  cartilage  of  the  rib  or  ribs  above;  the  eleventh  and 
twelfth  are  called  floating  ribs,  as  their  anterior  extremities  are  loose 
in  the  abdominal  wall.  The  ribs  increase  in  length  from  the  first 
to  the  seventh  or  eighth,  decreasing  from  the  eighth  to  the  twelfth. 
They  are  approximately  parallel  with  the  exception  of  the  eleventh 
and  twelfth,  which  slant  somewhat  more  downward. 

It  must  be  remembered  that  ribs  are  lower  at  their  front  ends  than 
at  their  vertebral  connection,  so  that  if  it  is  desired  to  rotate  a  vertebra 
by  pressure  on  a  rib,  the  rib  horizontally  opposite  the  vertebra  is  not 
to  be  chosen.     It  has  been  shown^  in  the  cadaver  (i)  that  rotation  of 


Fig.  7. — Horizontal  Section  of  Thorax  at  Seventh  Dorsal  Vertebra  Showing  the 
Position  of  the  Vertebral  Bodies. — (From  Braun's  Atlas-Corning.) 

vertebrae  may  be  produced,  when  the  extremities  of  the  spine  are 
fixed,  by  pressure  upon  any  of  the  intermediate  ribs;  (2)  that  the 
vertebrae  attached  to  the  ribs  on  which  pressure  is  made  are  the 
most  affected;  (3)  that  the  rotation  never  equals  the  rib  excursion; 
(4)  that  the  most  effective  points  for  pressure  or  counterpressure  are 
as  far  as  possible  from  the  midline  anteriorly  and  posteriorly  except 
on  the  lowest  four  ribs. 

STERNUM 

The  sternum  or  breast-bone  is  situated  in  the  median  line  of  the 
trunk,  completing  the  thoracic  cage  anteriorly.  The  sternum  is  a 
flat  bone,  and  as  a  whole,  it  lies  directed  obliquely  forward  and 

1  Keene:  "Amer.  Jour,  of  Orth.  Sur.,"  July,  1906,  page  69. 


SHAPE  AND  BOUNDARIES  OF  THE  THORAX 


15 


downward.     It  consists  of  three  parts — the  manubrium  sterni,  the 
gladiolus,  and  the  ensiform  cartilage  or  xiphoid  process. 


SHAPE  AND  BOUNDARIES  OF  THE  THORAX 

In  shape  the  thorax  is  somewhat  conical,  larger  behind  than  in 
front  and  compressed  antero-posteriorly.  The  posterior  wall  is 
formed  by  the  thoracic  vertebrae,  and  by  the  ribs,  from  their  heads 
to  their  angles,  and  is  convex  vertically  and  horizontally.  Laterally 
the  cage  is  formed  by  the  shafts  of  the  ribs;  it  is  somewhat  convex 
vertically  and  sharply  convex  from  before  backward.     The  anterior 


Fibrous  ring  of  in- 
tervertebral fibro- 
cartilage 


Anterior  radi- 
ate or  stellate 
ligament 


Costo-central 
synovial  sac 


Pulpy  nucleus  of 
intervertebral  fibro- 
cartilage 


Middle  costo- 
transverse liga- 
ment 


Costo-trans verse  synovial  sac 


Posterior  costo-transverse  ligament 


Fig.  8. — Horizontal  Section  through  an  Intervertebral  Fibro-cartilage  and  the 
Corresponding  Ribs. — (Morris's  "Anatomy.") 

surface,  slightly  convex  and  directed  forward  and  downward,  is 
formed  by  the  sternum  and  the  costal  cartilages.  The  plane  of  the 
superior  opening  or  inlet  of  the  thorax  is  inclined  forward  and 
downward,  showing  a  greater  obliquity  in  women  than  in  men. 
The  inferior  border  of  the  thoracic  cage  is  formed  by  the  twelfth 
thoracic  vertebra,  the  loWer  borders  of  the  twelfth  rib,  and  by  two 
curved  lines,  extending  from  the  anterior  extremities  of  the  last  rib 
to  the  inferior  angles  of  the  gladiolus,  touching  the  anterior  extremi- 
ties of  the  eleventh  rib  and  the  costal  cartilages  of  the  tentli,  ninth, 
and  eighth  ribs.  The  angle  formed  by  these  lines  is  known  as 
the  subcostal  angle.  The  inferior  surface  of  the  thorax  is  directed 
forward  and  downward. 


i6 


ANATOMY    OF   VERTEBRAL    COLUMN    AND    THORAX 


MUSCLES  OF  THE  SPINE  AND  THORAX 

The  general  grouping  and  arrangement  of  the  muscles  in  their 
relation  to  the  spine  has  an  important  practical  bearing  on  scoliosis. 
The  spine  lies  toward  the  back  of  a  more  or  less  cylindrical  muscular 


Fig.  9. — G.  Herman  Meyer.  The 
Two  Oblique  Muscle  Pulls. — (Feiss.) 
On  the  left  the  descending  obHque.  a. 
External  intercostals;  6,  descending  ob- 
lique or  externus  abdominis.  On  the  right- 
the  ascending  oblique  muscle  pull,  c. 
Descending  oblique  or  internus  abdominis; 
d,  internal  intercostals;  e,  scalenus  colli;/, 
cremaster. 


Fig.  10. — G.  Herman  Meyer.  The 
Scheme  OF  the  Torso  Musculature  In- 
dicating THE  Direction  of  the  Various 
Muscle  Pulls. — {Feiss.) 

a.  Posterior  longitudinal  muscle  pull 
(sacrospinalis) ;  b,  anterior  longitudinal 
muscle  pull;  c,  oblique  descending  muscle 
pull;  d,  oblique  ascending  muscle  pull; 
e,  transverse  muscle  pull. 


tube  of  which  the  adbominal  muscles  form  the  front.  Of  muscles 
directly  attached  to  the  spine  there  are  two  varieties:  (i)  muscles 
running  from  one  part  of  the  spine  to  another  part  and  to  the  head; 
(2)  muscles  running  from  the  spine  to  the  pelvis  or  shoulder-girdle. 
The  abdominal  muscles  by  their  attachment  to  the  thorax,  which  is 
comparatively  rigid,  have  an  action  on  the  spine.     By  the  combined 


MUSCLES 


17 


action  of  these  three  the  erect  position  is  maintained,  or  any  variation 
from  it  is  accomplished. 

In  making  a  side  flexion  of  the  spine  from  the  erect  position,  for 
example,  no  one  muscle  or  group  of  muscles  is  alone  active,  but  it 
implies  a  concerted  and  coordinated  action  of  all  the  groups  men- 


FiG.  II. — G.  Herman  Meyer.  The 
System  of  the  Sacrospinalis. — (Feiss.) 
a,  Spinalis;  6,  longissimus  dorsi;  c,  trans- 
versalis  cervicis;  d,  trachelomastoideus; 
e,  ileocostalis;  /,  ascendens  cervices;  g, 
ileolumbalis  (hinder  portion  of  m.  quad- 
ratus  lumborum  Auct.);  /;,  obliquus  capi- 
tis inferior;  i,  obliquus  capitis  superior;  k, 
rectus  capitis  posterior  major;  /,  rectus 
capitis  posterior  minor. 


Fig.   12. — G.     Herman    Meyer.     An- 
terior LoNGITUDIN.\L   MUSCLES    OF    THE 

Trunk. — (Feiss.) 

a,     Sternocleido-mastoideus;    6,    rectus 
abdominis;  c,  pyramidalis. 


tioned,  as  well  as  of  the  muscles  of  the  lower  extremities,  to  keep  the 
balance  and  perform  the  bending.  The  maintenance  of  the  spine 
in  the  upright  position  by  the  muscles  has  been  compared  to  the  way 
in  which  a  flagstaff  is  held  upright  by  stays  reaching  from  the  top  of 
the  staff  to  the  ground.     Although  there  is  no  one  muscle  running 


1 8  ANATOMY   OF  VERTEBRAL   COLUMN   AND    THORAX 

from  the  head  to  the  pelvis,  there  is  a  continuous  set  of  muscles 
supplementing  each  other's  action.  For  example,  in  the  anterior 
line  the  sternomastoid  runs  from  the  skull  to  the  front  of  the  top  of 
the  thorax,  the  sternum  connects  the  upper  and  lower  ribs  and  forms 
a  rigid  piece,  and  the  lower  thorax  is  connected  with  the  pelvis  by 
the  rectus  abdominis  muscle.  In  the  back  the  continuity  of  musculaij 
action  is  shown  by  the  fact  that  before  the  top  insertion  of  the  longis- 
simus  dorsi  has  been  reached,  the  complexus  and  transversalis  cervicis 
have  begun.  The  whole  conception  of  muscular  action  in  its  relation 
to  gymnastics  is  simplified  by  remembering  the  continuity  of  the 
muscular  tube  from  the  head  to  the  pelvis. 

The  thorax  represents  a  comparatively  fixed  cage  inserted  in  a 
structure  quite  movable  above  and  below  it;  muscles  attached  to  the 
thorax  are  therefore  indirectly  attached  to  the  spine.  The  compara- 
tive rigidity  of  the  thoracic  part  of  the  spine  is  due  to  the  fact  that 
the  majority  of  the  ribs  are  attached  posteriorly  between  two 
vertebras,  that  they  pass  forward  to  be  also  attached  to  the  sternum, 
and  that  the  whole  structure  is  one  well  calculated  to  prevent 
physiological  side  bending  or  extensive  forward  or  backward  motion 
in  that  region;  the  cage  must  therefore  largely  move  as  a  whole. 

It  has  been  pointed  out  that  the  dorsqlumbar  junction  is  a  dividing 
point  for  important  muscular  origins  and  insertions  above  and  below 
it,  e.g.,  the  psoas  muscles  originate  largely  below  it  and  the  trapezius 
above  it,  and  that  it  forms  a  weak  and  movable  part  of  the  spine  for 
this  reason.  More  important  than  this  is  the  fact  that  muscles 
connecting  the  thorax  and  pelvis  will  move  the  spine  where  the  rigid 
dorsal  region  changes  to  the  movable  lumbar  region  and  that  a  large 
number  of  muscles  will  therefore  express  their  contraction  by  motion 
at  the  dorsolumbar  junction.  A  similar  weak  and  movable  part 
of  the  spine  is  said  to  exist  at  the  cervicodorsal  junction,  where 
important  muscles  (splenius  and  rhomboids)  have  a  dividing  point. 

NERVE-SUPPLY 

The  spinal  nerves  emerge  from  the  spinal  canal  through  the  inter- 
vertebral foramina  and  are  distributed  to  the  integument  and  muscles 
all  over  the  body.  Eight  are  cervical  nerves  (the  first  passing  over 
the  atlas),  twelve  dorsal,  five  lumbar,  five  sacral,  and  one  coccygeal. 
Each  nerve  is  formed  by  the  union  of  two  nerve  roots,  which  occurs 
outside  of  the  spinal  cord  and  just  inside  of  or  at  the  intervertebral 
foramen.     The  anterior,  motor,  or  efferent  fibers  come  from  the 


NERVE- SUPPLY 

MOTOR  SENSORY 


19 

REFLEX 


Sterno-mastoid 
j^  Trapezius 
>  Diaphragm 

\  Serratus    T 
/  Shoulder 

Arm  J  mu 

Hand  ] 

(ulnar  lowest) 


>  Neck  and  scalp 

>  Neck  and  shoulder 


Shoulder 

Arm 

Hand 


Scapular 


Intercostal 
muscles 


Abdominal 
muscles 


Front  of  thorax 


J-  Xiphoid  area 

J 


Abdomen 
(Umbilicus  loth) 


1  Buttock,  upper 
}     part 
J   J 


}  Epigastric 

I 
I 


Abdominal 


Flexors,  hip 


I  Extensors,  knee    |  | 

Adductors  ]  hip!  [  '^^^^'^ 


Groin  and  scrotum 
(front) 

outer  side 


front 


Abductors 


\  j  Extensors(?) 
Flexors,  knee(?) 

Muscles  of  leg 
moving  foot 


inner  side 
Leg,  inner  side 
Buttock,  lower 
part 

•  \  Back  of  thigh 

I      I  except  in- 
iFoo'^t     I    ""P-* 


Cremasteric 

\  Knee-joint 

J 


Gluteal 

Foot-clonus 
Plantar 


^^""m^uscle^s^"^^   '  }  Perinaum  and  anus 


!  1  Skin  from  coccyx 
I  J      to  anus 


Fig.  13. — Diagram  and  Table  showing  the  Approximate  Relation  to  the  Spinal 
Nerves  of  the  Various  Motor,  Sensory,  and  Reflex  Functions  of  the  Spinal  Cord. 
(Arranged  by  Dr.  Gowers  from  anatomical  and  pathological  data). — (Morris's  "Anatomy.") 


20  ANATOMY   OF   VERTEBRAL    COLUMN   AND    THORAX  * 

cells  of  the  anterior  horn  of  the  cord;  the  posterior,  sensory,  or 
afferent  fibers  .emerge  from  the  cells  of  the  posterior  horn  on  the  same 
side  of  the  cord.  The  nerve  formed  by  these  two  roots  on  leaving 
the  intervertebral  foramen  divides  into  an  anterior  and  posterior 
branch,  each  with  motor  and  sensory  fibers.  The  posterior  divisions 
are  small  and  supply  the  skin  and  muscles  of  the  back.  The  anterior 
divisions  are  distributed  to  the  neck,  the  front  and  sides  of  the  trunk, 
and  to  the  extremities.  Each  anterior  division  is  connected  with 
a  plexus,  ganglion,  or  nerve  of  the  sympathetic  system. 

EVOLUTION  OF  THE  SPINE 

The  history  of  the  spine  in  its  evolution  is  of  interest.  In  the 
Clyclostomata  the  vertebral  column  consists  of  a  non-segmented, 
homogeneous,  cartilaginous  rod.  Articular  processes  first  appear 
in  the  Rays  and  Teleostei.  The  backbone  of  the  lower  fishes  con- 
sists of  a  series  of  bony  discs  bound  together  by  elastic  intervertebral 
discs.  It  would  seem  from  the  history  of  the  spine  as  if  articular 
processes  developed  concomitantly  with  the  elaboration  of  struc- 
ture, and  as  if  they  .were  incidental  to  its  use  rather  than  factors 
determining  of  themselves  its  types  of  motion. 

As  will  be  mentioned  in  a  later  section,  the  human  spine,  from 
an  evolutionary  point  of  view,  is  practically  the  quadruped  spine 
set  on  end,  a  matter  which  has  a  distinct  bearing  on  its  weaknesses 
as  an  upright  supporting  column. 

OSSIFICATION 

The  ossification  of  a  vertebra  occurs  from  three  primary  centers, 
one  for  the  body  and  one  for  each  lateral  mass.  These  appear  in  the 
sixth  week,  and  in  the  cervical  region  the  lateral  centers  are  the  first 
to  appear,  while  in  the  dorsal  region  the  one  for  the  body  is  the  first 
seen.  The  center  for  the  body  is  often  double  in  appearance  if  not 
in  reality.  The  centers  for  the  lateral  masses  are  found  near  the 
bases  of  the  articular  processes  and  from  them  form  the  pedicles, 
laminae,  articular  processes,  and  a  large  part  of  the  transverse  and 
spinous  processes,  the  bodies  of  the  vertebrae  forming  from  the  other 
center.  The  vertebral  epiphyses  serve  to  assist  in  the  formation  of 
joints,  to  provide  for  the  attachment  of  ligaments  and  tendons,  and 
to  increase  the  development  in  length  of  the  bone  of  which  they  form 
a  part.     At  about  puberty  appear  five  other  secondary  or  comple- 


PHYSIOLOGICAL   CURVES  21 

mentary  centers,  one  at  the  tip  of  the  spinous  process,  one  at  the  tip 
of  each  transverse  process,  and  one  at  the  upper  and  one  at  the  lower 
surface  of  each  body,  occurring  as  a  flat  meniscus  at  about  the  seven- 
teenth year  and  uniting  to  the  vertebral  body  a  few  years  later 
(twentieth  year).  Inasmuch  as  vertebral  growth  occurs  at  each  of 
these  epiphyses,  this  complicated  method  of  ossification  is  important 
because  the  injury  or  disease  of  one  of  these  epiphyseal  lines  might 
lead  to  serious  bony  deformity  of  the  vertebra  (Figs.  14  and  15). 

ELASTICITY  OF  SPINE 

The  spinal  column  is  capable  of  some  movement  in  all  directions. 
The  elasticity  of  the  intervertebral  discs  is  such  that  the  ball-and- 
socket  joint  between  each  two  vertebrae  allows  motion  between  them 
in  any  plane  or  direction  until  limited  by  bony  contact  and  ligamen- 
tous or  muscular  tension.  It  also  allows  rotation  to  occur  between 
two  separate  vertebra  in  an  approximately  horizontal  plane.  Bone 
is  slightly  compressible,  but  this  is  not  a  factor  of  importance  in  con- 
tributing to  vertebral  flexibility. 
^  In  childhood  the  vertebrae  are  largely  cartilaginous,  and  the  in- 
creasing proportion  of  bone,  along  with  the  diminishing  proportion  of 
cartilage,  causes  a  decrease  of  flexibility  from  youth  to  adult  age, 
aside  from  the  fact  that  the  flexibility  of  all  joints  is  greater  in  youth. 
With  old  age  the  capability  of  movement  of  the  spine  is  greatly  less- 
ened on  account  of  the  atrophy  of  the  intervertebral  discs. 

PLANES  OF  THE  BODY       . 

The  planes  of  the  body  will  be  frequently  spoken  of  and  should  be 
defined.  The  frontal  plane  is  a  vertical  and  transverse  one.  The 
sagittal  or  antero-posterior  plane  runs  in  the  antero-posterior  axis. 
The  term  horizontal  plane  is  self-explanatory. 

PHYSIOLOGICAL  CURVES  (ANTERO-POSTERIOR) 

The  physiological  curves,  so  called,  are  antero-posterior  curves 
and  are  important.     They  are  three  in  number. 

The  dorsal  (backward)  curve  is  the  first  to  become  evident,  and 
was  found  present  in  86  per  cent,  of  normal  children  under  one  year 
old  when  lying  on  the  face  and  in  99  per  cent,  of  children  over  one 
year  old.     In  children  under  six  months  this  backward  convexity 


22  ANATOMY    OF  VERTEBRAL    COLUMN   AND    THORAX 

included  the  lumbar  region,  but  after  this  age  it  did  not  as  a  rule,^ 
the  lumbar  curve  then  occurring  at  the  expense  of  the  dorsal  curve. 
The  lumbar  (forward)  curve  in  lying  showed  frequently  after  the 
age  of  one  year  and  in  a  very  large  majority  of  cases  after  the  age 
of  three  years.  The  lumbar  curve  when  it  formed  took  the  place 
of  part  of  the  original  backward  dorsal  curve  and  was  more  marked 

Epiphyseal  plate  or  disc 

•Mammillary  tubercle 

"  Transverse  process 

■  Spinous  process 
Epiphj  seal  plate  or  disc 

Fig.  14. — Lumbar  Vertebra  at  the  Eighteenth  Year  with  Secondary  Centers. — 
{Morris's  "Anatomy.") 

in  standing  than  in  lying.  In  standing  it  was  present  after  the  age 
of  two  years  in  a  very  large  majority  of  cases,  the  exceptions  being 
usually  in  children  under  three  who  had  not  walked.  The  lumbar 
curve  in  childhood  is  obhterated  in  the  sitting  position,  only  four  chil- 
dren of  those  examined  between  the  ages  of  nine  and  thirteen  showing 
such  a  curve  in  the  sitting  position. 


Neuro-central  suture 
Centrum 

Fig.  15. — Ossification  of  the  Fifth  Lumbar  Vertebra. — {Morris's  "Anatomy.") 

The  cervical  (forward)  curve  could  not  be  accurately  determined 
in  either  standing  or  lying  in  the  youngest  children,  but  after  the  age 
of  fourteen  months  this  curve  was  observed  in  standing. 

In  the  adult,  the  part  played  by  the  bodies  of  the  vertebrae  and  the 
discs  in  producing  the  physiological  curves  is  shown  by  the  following 
table: 

'  Lovett,  Davis,  and  Montgomery:  "Arch,  di  Ortopedia,"  iqcO,  v  and  vi, 
page  372. 


PHYSIOLOGICAL   CURVES  23 

Difference  between  the  Sums  of  the  Anterior  and  Posterior  Borders 

Vertebrae  Discs 

Cervical  region 1.3  imn-  7  •  8  mm. 

Dorsal  region 13.3  mm.  9.2  mm. 

Lumbar  region 6.7  mm.  21.1mm. 

The  cervical  curve  is  formed  principally  by  the  intervertebral  discs. 
It  is  a  fairly  mobile  curve,  and  may  be  straightened  by  suspension. 
The  dorsal  curve  is  formed  chiefly  by  the 
bodies   of   the  vertebrae;    it  is  a  rigid       pS^^'^*™****' "'''*'■ 
curve  and  cannot  be  obliterated.     The 
lumbar  physiological  curve  is  produced 
mainly  by  the  greater  anterior  height 
of  the  intervertebral  discs  and  is  there- 
fore mobile. 

A   slight  physiological  lateral  curve 
convex  to  the  right  has  long  been  recog- 
nized in  the  spine.     It  has  been  attri-  ^'*liS>'^^ 
buted  to  the  pressure  of  the  aorta  on  the  l^^«^ 
vertebral  bodies,  to  excessive  use  of  the  ^  ^1 
right  side  of  the  body  in  certain  occu- 
pations, and  to  right-handedness.     The 
almost  constant  occurrence  of  the  curve 
indicates   a   common   cause,    which   is               :^^i 
most    probably   aortic   pressure.     The 
asymmetry  extends  from  the  fifth  dor-               , ;».«_ 
sal  to  the  second  or  third  lumbar  ver-                W^i^- 
tebra.     The  bod}^  of  the  fifth  dorsal  ver-                 .m^mr>f 
tebra  is  flattened  on  the -left  side,  and                  «*<s^-« 
the  discs  above  and  below  are  similarly 
affected.     There  is  a  groove  from  x^i  to     ^^^-o'/rNlw-BORN  iSx.""'^ 
2   cm.  broad   passing  downward  in  a 

spiral  direction,  following  the  course  of  the  aorta,  to  the  anterior 
surface  of  the  second  or  third  lumbar  vertebra.  The  discs  between 
these  vertebras  are  usually  less  projecting  than  the  others,  and  if 
the  cutting  av/ay  of  the  vertebra  cannot  be  seen  the  flattening  of 
the  disc  is  always  apparent.^ 

PELVIC  INCLINATION 

The  position  of  the  pelvis  in  relation  to  the  horizontal  plane 

would  be  of  importance  in  relation  to  scoliosis  and  faulty  attitude  if 

it  could  be  accurately  measured  in  the  li\dng  subject. 

^Pere:  "Les  courb.   lat.   norm   du   Rachis  humaine,"   These   de   Toulouse, 
1900. 


24 


ANATOMY    OF  VERTEBRAL   COLUMN   AND    THORAX 


If  the  front  part  of  the  pelvis  is  lowered  and  the  back  part  cor- 
respondingly tilted  up  it  is  spoken  of  as  "increased  inclination"  of  the 
pelvis.  If  the  front  part  is  raised  and  the  back  part  lowered  it  is 
spoken  of  as  "diminished  inclination."  With  the  former  is  asso- 
ciated an  increase  of  the  lumbar  physiological  curve,  and  with  the 
latter  a  flattening  of  it.     Changes  in  inclination  of  the  pelvis  must 


GIRL 

r/a  YRS 

Sitting   Front 


-7^"C 


Fig. 


.4"!- 


17. — ^Tracings  of  Physiological  Curves  of  Normal  Children:  on  the  Left  of 
A  Girl  of  One  and  a  Half  Years,  on  the  Right  of  a  Girl  of  Eleven. 


form  an  important  element  in  the  faulty  attitude  to  be  spoken  of 
as  round  shoulders. 

The  internal  or  true  conjugate  diameter  (conjugata  vera)  of  the 
pelvis  is  a  line  from  the  sacrolumbar  junction  to  the  top  of  the  sym- 
physis pubis  and  is  generally  accepted  as  the  line  by  which  pelvic 
inclination  is  to  be  determined.  The  angle  which  this  hne  makes 
with  the  horizon  when  the  patient  stands  erect  is  spoken  of  as  the 


PELVIC   INCLINATION  2$ 

"angle  of  pelvic  inclination,"  and  the  observers  do  not  wholly  agree 
in  their  results.  It  is  probable  that  no  measurements  of  pelvic 
inclination  in  the  living  subject  are  sufficiently  accurate  to  be  of 
value. 

In  men  the  variation  in  the  average  of  collected  results  is  from  44 
degrees  to  60  degrees,  and  in  women  from  41  degrees  to  65  degrees. 
The  results  of  Prochovnik  were  obtained  by  the  most  accurate 
method  of  any  and  the  research  was  conducted  entirely  on  living 
subjects.  The  variation  in  men,  according  to  his  figures,  was  from  26 
degrees  to  76  degrees,  and  in  women  from  40.5  degrees  to  71  degrees. 

A  research  by  Reynolds  and  Lovett^  was  undertaken  as  to  the 
mechanics  of  the  antero-posterior  position  in  the  upright  living  indi- 
vidual, in  which  research  a  determination  of  pelvic  inclination  and  its 
variations  under  varying  static  conditions  would  have  been  of  pre- 
sumable value,  but  after  months  of  experimentation  with  various 
methods  the  investigators  came  to  the  conclusion  that  it  was  impos- 
sible to  measure  the  variations  in  the  inclination  of  the  pelvis  in  a 
living  individual  with  sufficient  accuracy  to  be  of  any  practical 
value. 

The  following  figures  are  therefore  quoted  in  the  belief  that  they 
can  only  be  approximate  and  that  they  must  be  taken  only  in  the 
most  general  way.  They  are  partly  obtained  from  the  living,  but  in 
many  instances  are  from  the  cadaver. 

Average  in.  Average  in 

men  women 

Year  1745,  Miiller 45  degrees  

Year  1825,  Nagele^ 60       "  

Year  1836,  Weber  Brothers^ 65  degrees 

Year  1841,  Krause*.. 60       "  60       " 

Year  1873,  Meyer^ 55       "  50       " 

Year  1882,  Prochovnik.6 54- 17"  51 -72" 

Year  1898,  Henggeler^ 44       "  41 .  i  " 

In  1 910  Engelhard^  published  some  observations  on  pelvic  inclina- 
tion in  living  children  from  six  to  fourteen.  The  extremes  of  inclina- 
tion were  from  21  degrees  to  46  degrees  to  the  horizontal  with  an 
average  inclination  of  32  degrees. 

^  .E  Reynolds  and  R.  W.  Lovett:    "Journ.  Am.  Med.  Assn.,"  Mar.  26,  1910. 

2  "Das  Weibl  Becken,"  etc.,  Carlsruhe,  1825. 

^  "Mech.  d.  Menschl.  Gel^erkzeuge,"  Gottingen,  1836. 

■*  "Hdbch.  d.  Mensch.  Anat.  Hauft.,"  i,  i,  324,  Hanover,  1841. 

^  "  Mailer's  Archiv,"  1873,  g. 

«  "Archiv  f.  Gyn.,"  1882,  xix,  i. 

''  "Zeitsch.  f.  orth.  Chir.,"  xii,  4,  613. 

^  "Zeitsch.  f.  orth.  Chir.,"  xxvii,  page  i,  1910. 


26 


ANATOMY  OF  VERTEBRAL  COLUMN  AND  THORAX 


Seventy-six  males  and  eighty  females,  all  apparently  normal,  over 
the  age  of  fifteen  were  investigated  and  tabulated  by  Prochovnik  as 
follows: 

Least  inclination  Greatest  Average 

Males 26      degrees        76  degrees  51.72  degrees 

Females 40.5       "  71       "'  54- 17       " 

The  grouping  of  the  results  suggests  that  a  normal  pelvis  shows  an 
inclination  of  from  50  to  60  degrees,  that  there  is  a  subnormal  zone 

from  45  to  50  degrees,  a  supra- 
normal  of  60  to  65  degrees,  but 
that  an  inclination  above  65  de- 
grees or  below  45  degrees  is  to  be 
regarded  as  pathological.  The 
figures  given  refer  to  the  external 
conjugate  and  are  a  little  higher 
when  the  internal  conjugate  is 
taken  as  determining  the  angle  of 
inclination. 

The  whole  subject  of  pelvic  in- 
clination and  its  variations,  the 
influences  of  such  changes  of  in- 
clination on  static  conditions,  and 
the  difference  of  inclination  be- 
tween children  and  adults- must 
therefore  be  left  in  an  unsatisfactory  and  unsettled  condition. 


Fig.  18. — Female  Pelvis,  Median 
Section. — {Spalteholz.) 
The  solid  line  running  up  and  back  from 
the  symphysis  indicates  the  "external  con- 
jugate diameter." 


SURFACE  ANATOMY  OF  THE  BACK 

The  position  of  the  spine  in  the  median  line  of  the  body  is  indicated 
on  the  normal  back  by  a  longitudinal  furrow  (median  furrow)  extend- 
ing from  the  occipital  bone  to  the  sacrum.  The  lower  end  of  the 
furrow  corresponds  to  the  interval  between  the  fifth  lumbar  vertebra 
and  the  sacrum.  In  the  cervical  region  this  furrow  lies  between  the 
trapezii  and  complexi,  and  in  the  dorsal  and  lumbar  regions  it  lies 
between  the  erector  spinas  muscles.  It  is  usually  most  marked  in  the 
upper  lumbar  and  lower  dorsal  regions. 

Identification  of  Vertebra. — In  this  median  furrow  the  spinous  proc- 
esses of  the  lower  cervical  vertebras  can  be  felt  easily,  but  the  spine 
of  the  second  cervical  vertebra  can  be  reached  by  deep  pressure  in 
a  relaxed  neck;  in  a  poorly  developed  individual  they  can  be  seen 
in  the  erect  position,  and  in  one  well  developed  in  forward  bending. 


SURFACE  ANATOMY  OF  THE  BACK  27 

The  spinous  process  of  the  seventh  cervical  vertebra  is  usually  quite 
prominent,  though  that  of  the  first  thoracic  may  be  still  more  so.  In 
proceeding  downward  the  root  of  the  spine  of  the  scapula  should  be 
found  opposite  the  spinous  process  of  the  third  dorsal  vertebra,  and 
the  inferior  angle  of  the  scapula  opposite  that  of  the  seventh  dorsal 
vertebra.  The  spine  of  the  fourth  lumbar  vertebra  is  on  a  level  with 
the  highest  points  of  the  ihac  crests.  The  spinous  process  of  the 
fifth  lumbar  vertebra  is  very  short,  and  usually  forms  a  slight  de- 
pression instead  of  a  prominence.  The  third  sacral  vertebra  is  on  the 
line  drawn  between  the  posterior  superior  spines  of  the  ilium,  and  this 
line  lies  over  the  sacro-iliac  joints.  The  twelfth  dorsal  vertebra  is 
found  by  counting  down  from  the  seventh  dorsal  and  up  from  the 
fourth  lumbar  vertebra,  and  any  vertebra  may  be  found  in  this  way. 
Of  the  methods  of  identification  this  is  the  most  reliable.  In  the 
dorsal  region  the  obliquity  of  the  spinous  processes  causes  the  tip  of 
each  to  be  opposite  the  body  of  the  vertebra  next  below  it.  So  the 
spine  of  the  second  dorsal  vertebra  corresponds  to  the  head  of  the 
third  rib,  but  the  eleventh  and  twelfth  dorsal  spines  are  opposite  the 
heads  of  the  eleventh  and  twelfth  ribs.  The  spinous  processes  of 
the  lumbar  vertebra  are  opposite  the  lower  parts  of  the  correspond- 
ing bodies  and  the  discs  below  them. 

In  the  adult  the  spinal  cord  ends  at  the  lower  border  of  the  first 
lumbar  vertebra;  in  children  the  cord  terminates  at  the  lower  border 
of  the  third  lumbar  vertebra. 

Muscles. — The  outline  of  the  neck  posteriorly  is  formed  by  the 
trapezii  and  underlying  muscles.  The  surface  of  the  shoulder  is 
shaped  by  the  deltoid  and  the  muscles  underlying  the  trapezius. 
The  posterior  border  of  the  axilla  is  formed  by  the  latissimus  dorsi, 
which  also  takes  part  in  forming  the  contour  of  the  lower  part  of  the 
back.  In  action  the  anterior  edge  of  the  latissimus  dorsi  may  be  seen 
as  a  fold  extending  from  the  crest  of  the  ilium  to  the  axilla.  The 
erector  spinse  muscles  form  a  rounded  prominence  longitudinally  on 
either  side  of  the  spine  in  the  lumbar  region. 

The  following  table  from  Gray's  "Anatomy"  gives  the  relation  of 
the  spines  of  the  vertebrae  to  important  organs: 


28 


ANATOMY    OF   VERTEBRAL    COLUMN    AND    THOR.^X 


T/VBULAR  Pr.AN  OF   PaRTS  OPPOSITE  THE  SPINES  OF  THE  VeRTEBR-^E   (GrAY) 


Cervical. 


Dorsal. 


Lumbar. 


5th.  Cricoid  cartilage.     Esophagus  begins. 

7th.  Apex  of  lung:  higher  in  the  female  than  in  the  male. 

3d.  Aorta  reaches  spine.     Ape.x  of  lower  lobe  of  lung.     Angle 

of  bifurcation  of  trachea. 
4th.  Aortic  arch  ends.     Upper  level  of  heart. 
8th.  Lower  level  of  heart.     Central  tendon  of  diaphragm. 
9th.  Esophagus  and  vena  cava  through  diaphragm.     Upper 

edge  of  spleen, 
loth.  Lower  edge  of  lung.     Liver  comes  to  surface  posteriorly. 

Cardiac  orifice  of  stomach, 
nth.  Lower  border  of  spleen.     Renal  capsule. 
12th.  Lowest  part  of  pleura.     Aorta  through  diaphragm.     Py- 
lorus. 
I  St.  Renal  arteries.     Pelvis  of  kidney. 
2d.  Termination  of  spinal  cord.     Pancreas.     Duodenum  just 

below.     Receptaculum  chyli. 
3d.  Umbilicus.     Lower  border  of  kidney. 
4th.  Division  of  aorta.     Highest  part  of  ilium. 


Points  for  Lateral  Corrective  Pressure. — The  points  at  which  cor- 
rective side  pressure  may  be  applied  to  the  spine  are  determined  by 
anatomical  conditions.  The  important  structures  lying  on  both 
sides  of  the  spine  in  the  cervical  and  lumbar  regions  make  it  impos- 
sible to  use  effective  side  pressure  upon  a  curved  spine  in  these  re- 
gions. In  the  dorsal  region  side  pressure  on  the  ribs  is  eff'ective  on 
the  vertebrae,  but  it  cannot  be  exerted  on  the  upper  vertebrae  higher, 
of  course,  than  the  axilla.  The  anterior  border  of  the  axilla  is  formed 
by  the  pectoralis  major  muscle  and  is  in  the  line  of  the  fifth  rib. 
This  rib  articulates  with  both  the  fourth  and  fifth  dorsal  vertebrae. 
Although  with  the  arm  nearly  at  the  side  the  third  rib  may  be  reached 
by  the  exploring  hand,  side  pressure  on  the  thorax  cannot  be  exerted 
efficiently  above  the  fourth  or  fifth  rib. 


CHAPTER  III 
THE  MOVEMENTS  OF  THE  SPINE  ^ 

The  movements  of  the  human  spine  are  three  in  number: 

(i)  Flexion,  (2)  extension,  and  (3)  a  compound  movement — side 
bending-rotation. 

The  statement  that  there  are  four  movements  (flexion,  extension, 
rotation  and  side  bending)  is  wholly  incorrect,  as  neither  side  bending 
nor  rotation  exists  in  a  pure  form  as  may  be  demonstrated  on  any 
normal  child.  The  statement  that  such  movements  exist  as  pure 
movements  necessarily  leads  to  a  false  basis  for  gymnastic  exercises 
and  obscures  the  whole  mechanism  of  scoliosis. 

As  long  ago  as  1844  Henry  J.  Bigelow  wrote:  "The  principle  of 
torsion  is  illustrated  by  bending  a  flat  blade  of  grass  or  a  flat,  flexible 
stick  in  the  direction  of  its  width.  The  center  immediately  rotates 
upon  its  longitudinal  axis  to  bend  flatwise  in  the  direction  of  its  thick- 
ness. In  the  same  way  the  spine,  laterally  flexed,  turns  upon  its 
vertical  axis  to  yield  in  its  shortest  or  antero-posterior  diameter." 
Occasional  references  are  found  to  the  association  of  torsion  with 
lateral  flexion,  but  no  general  recognition  of  the  relation  between  the 
two  has  existed. 

The  human  spine  is  not  an  extremely  flexible  structure  taken  by 
itself;  much  of  its  apparent  flexibility  is  due  to  accessory  movements 
between  the  spine  and  the  pelvis  and  the  head.  An  extreme  forward 
flexion,  e.g.,  in  the  living  model  or  the  intact  cadaver,  with  the  flexed 
head,  the  drooping  shoulders,  and  the  rotated  pelvis,  impHes  a  greater 
curve  than  the  spine  itself  possesses.  It  is  surprising  to  see  in  the 
cadaver  how  comparatively  little  actual  mobility  is  possessed  by  the 
three  regions  of  the  spine  considered  separately,  or  by  the  whole  spine. 

The  application  of  this  is  obvious  without  extended  comment. 
If  active  or  passive  exercises  are  given  which  are  intended  to  take 
effect  upon  the  spine  alone  and  to  be  effective  there,  the  pelvis  must 
be  fixed.  If  this  is  not  done,  part  of  the  muscular  force  is  used  in 
displacing  the  pelvis  to  the  opposite  side  to  balance  the  body,  and 
the  movement  becomes  a  general  and  not  a  spinal  one. 

^R.  W.  Lovett:  "Bos.  Med.  and  Surg.  Jour.,"  June  4,  igco,  Oct.  31,  1901, 
Mar.  17,  1904,  Sept.  28,  1905;  "Amer.  Jour,  of  Anat.,"  ii,  4,  457. 

29 


3° 


THE    MOVEMENTS    OF    THE    SPINE 


I.  FLEXION  (FORWARD  BENDING) 

Is  a  pure  antero-posterior  movement  without  perceptible  rotation.  It  is  the 
most  evenly  distributed  of  the  spinal  movements,  and  in  extreme  flexion  the  out- 
line of  the  tips  of  the  spinous  processes  forms  a  curve  approaching  the  arc  of  a 
circle.  Most  of  the  movement  is  accomplished  in  the  lumbar  region,  which  in 
extreme  flexion  loses  most  of  its  forward  convexity,  but  in  adult  observations 
was  not  observed  to  become  convex  backward. 


Fig.   19. — Flexion  of  the  Spine  in  the  Model. 


The  dorsal  region  in  extreme  flexion  becomes  decidedly  more  convex  than  in 
the  upright  position.  The  twelfth  dorsal  vertebra  takes  part  in  flexion  more  as  a 
lumbar  than  as  a  dorsal  vertebra,  and  free  movement  occurs  below  it  and  fairly 
free  movement  between  the  eleventh  and  twelfth  vertebras. 

The  cervical  region  cannot  be  accurately  observed  or  measured  in  the  model. 
In  the  cadaver  it  dries  so  rapidly  that  no  conclusions  can  be  drawn  be5^ond  the 
statement  that  its  forward  convexity  may  be  obliterated  by  forcible  flexion  with 
the  hands. 


FLEXION 


31 


The  most  marked  flexion  of  the  spine  may  be  obtained  by  having  the  model 
sit  cross-legged  and  bend  forward  with  the  chest  between  the  knees.  Extreme 
passive  flexion  with  the  model  lying  on  the  side  is  not  so  great  as  that  obtained  by 
flexion  in  the  cross-legged  position. 

In  flexion  the  distance  of  the  seventh  cervical  vertebra  from  the  sacrum  when 
measured  along  the  spinous  processes  is  increased  over  the  same  measurement 
taken  in  standing  or  lying. 


Fig.  20. — -Hyperextensign  in  the  Model. 
The  head  is  supported  to  secure  steadiness. 


There  seems  to  be  no  constant  difference  in  the  amount  of  flexion  obtained  in 
the  standing  and  sitting  positions,  the  resultant  curve  being  practically  the  same. 
The  chief  difference  between  flexion  in  model  and  cadaver  seems  to  consist  in 
a  greater  relative  participation  of  the  dorsal  region  in  flexion  in  the  model. 

Measurements  and  tracings  of  the  spine  in  the  model  and  in  children  show 
the  relaxed  sitting  position  to  be  one  of  slight  flexion. 

Forward  flexion  of  the  spine  in  scoliosis  tends  to  straighten  the  curved  line  formed 
by  the  spinous  processes. 


32 


THE    MOVEMENTS    OF    THE    SPINE 


II.'hYPEREXTENSION  (BACKWARD  BENDING) 

Hyperextension  is  a  pure  antero-posterior  movement  of  the  spine  without 
perceptible  rotation.  It  is  not  an  evenly  distributed  movement,  but  occurs 
almost  wholly  in  the  lumbar  and  lower  two  dorsal  vertebra;.  A  tracing  taken  over 
the  spinous  processes  in  extreme  hyperextension  in  outline  resembles  a  hockey 
stick.  The  dorsal  region  is  but  little  affected,  being  slightly  straightened  by 
hyperextension.  The  bending  reaches  to  about  the  tenth  dorsal,  the  upper  dorsal 
region  showing  but  little  diminution  in  the  physiological  curve,  the  twelfth  dorsal 
vertebra,  and,  to  a  certain  extent,  the  eleventh,  behaving  as  do  the  lumbar 
vertebrae  in  hyperextension.  The  character  of  the  curve  obtained  in  marked 
hyperextension  is  practically  the  same,  whether  it  is  obtained  by  active  or  passive 

means,  and  whether  the  model  lies 
on  the  face  or  on  the  side,  or  stands, 
or  sits.  The  column  of  vertebral 
bodies  alone  shows  the  same  char- 
acter and  distribution  of  the  move- 
ment as  does  the  intact  spine  of  the 
cadaver.  The  illustration  (Fig.  21) 
shows  the  characteristic  rigidity  of 
the  dorsal  region  to  hyperextension. 
In  hyperextension,  the  distance 
from  the  seventh  cervical  vertebra 
to  the  sacrum,  measured  over  the 
spinous  processes,  is  decreased  from 
the  same  measurement  taken  in  the 
erect  position. 

Ilia.  LATERAL  FLEXION  (SIDE 
BENDING) 

Lateral  flexion  of  the  spine  does 
not  exist  as  a  pure  movement,  but 
is  to  be  considered  as  one  part  of  a 
compound  movement,  of  which  twist- 
ing or  rotation  forms  the  other  part. 
In  describing  this  side  bending  it  must  be  stated  that  the  character  and  distri- 
bution of  the  movement  vary  widely  according  to  the  degree  of  flexion  or  exten- 
sion of  the  spine  when  the  side  bending  is  made.  In  other  words,  there  is  no 
one  type  of  spinal  side  bending,  as  there  are  t^'pes  of  flexion  and  extension,  but 
the  character  and  distribution  of  the  movements  are  wholly  dependent  upon 
whether  the  spine  is  flexed,  erect,  or  hyperextended  when  the  side  bending  is 
performed. 

Side  bending  will  first  be  considered  alone  without  regard  to  the  rotation  caused 
by  it,  and  then  the  rotation  accompanying  each  kind  of  side  bending  will  be 
described. 

The  extent  and  distribution  of  forward  and  backward  bending  have  been 
investigated  in  children  from  six  to  fourteen  years  old  by  Engelhard, "^  and 


Fig.  21. — Hyperextension  in  the  Cad.a.ver. 


^  "Zeitsch.  fur  orth.  chir.,"  1910,  xxvii,  p.  i. 


SIDE   BENDING  T,^ 

Fig.  31  shows  the  amount  and  distribution  of  these  movements  as  formulated 
by  him  in  an  average  individual. 

Side  bending  in  lying  on  the  face  shows  a  more  evenly  distributed  lateral 
curve  than  does  that  in  the  erect  position.  The  character  of  the  curve  does  not 
change  essentially  when  the  shoulders  and  pelvis  are  held  and  the  middle  of  the 
trunk  pushed  to  one  side.     The  curve  in  this  position  of  the  spine  is  greater  in  the 


Fig.  22. — Side  Bending  to  the  Right  in  the  Flexed  Position  of  the  Spine  in  the 

Model. 

A  lateral  curve  convex  to  the  left  is  formed  and  the  vertebral  bodies  have  turned  to  the  left, 

as  shown  by  the  elevation  of  the  left  side  of  the  back. 

upper  lumbar  vertebrae  and  in  the  two  lower  dorsal  than  in  the  upper  part  of 
the  spine. 

Rotation  Accompanying  Side  Bending  Lying  on  the  Face. — With  the  cadaver 
lying  flat  on  the  face  on  the  table  no  rotation  in  side  bending  was  found  by  v. 
Meyer  and  in  some  experiments  by  Scliluthess;  it  was,  however,  found  by  Benno 
Schmidt.  With  the  cadaver  lying  prone  on  a  table  the  conditions,  of  course, 
are  against  rotation,  the  thorax  and  shoulders  being  to  a  certain  extent  held  against 
it_by  the  surface  of  the  table.  No  perceptible  rotation  is  noted  in  slight  side  bend- 
ing under  these  conditions,  but  the  vertebral  bodies  turn  to  the  concave  side  in 
3 


34 


THE    MOVEMENTS    OF    THE    SPINE 


marked  side  bending.  In  the  model  lying  flat  on  a  table  one  side  of  the  chest  is 
felt  to  press  on  the  table  harder  than  the  other  in  moderate  side  bending.  The 
point  is  not  of  great  importance,  as  the  practical  problem  is  that  of  the  behavior 
of  the  weight-be-.iring  spine. 

Side  bending  in  the  flexed  position  of  the  spine  is  a  more  evenly  distributed 
movement  in  which  the  dorsal  region  participates  more  and  the  lumbar  region 
less  than  in  the  erect  position.  The  greatest  deviation  from  a  line  connecting  the 
two  ends  of  the  spine  occurs  at  about  the  eighth  dorsal  vertebra  in  both  cadaver 


Fig.  23. — Side  Bending  in  the  Upright  Position  of  the  Model. 
The  movement  is  chiefly  located  at  the  dorsolumbar  junction. 


and  model.  In  short,  side  bending  occurs  higher  in  the  spine  in  flexion  than  in 
any  other  position,  the  lumbar  region  being  comparatively  locked  against  side 
bending  by  the  flexed  position.  The  more  marked  the  flexed  position,  the 
higher  in  the  spine  is  the  side  bending  localized. 

Rotation  Accompanying  Side  Bending  in  Flexion. — In  the  flexed  position  of  the 
spine,  side  bending  is  accompanied  by  rotation  of  the  vertebral  bodies  toward 
the  convexity  of  the  lateral  curve.  This  rotation  occurs  chiefly  in  the  dorsal 
region. 


SIDE   BENDING 


35 


Side  Bending  in  the  Erect  Position. — In  the  cadaver  side  bending  is  most 
marked  below  the  tenth  dorsal  vertebra,  and  the  dorsal  region  shares  but  slightly. 
The  lumbar  region  is  most  affected  in  its  upper  part,  but  shares  to  some  extent 
throughout.  Side  bending  in  the  erect  position  is,  therefore,  largely  a  movement 
occurring  in  the  neighborhood  of  and  below  the  lumbar  dorsal  junction.  It  shows 
the  same  characteristics  in  the  cadaver,  the  model,  and  the  child,  except  that  in 
the  two  last  named  the  dorsal  region  takes  a  greater  relative  part  than  in  the 
cadaver. 

Rotation  Accompanying  Side  Bending  in  the  Erect  Position. — In  this  position 
side  bending  causes  the  rotation  of  the  bodies  of  the  vertebrae  to  the  concave  side 
of  the  lateral  curve.  This,  however,  occurs  lower  down  in  the  spine  than  in  the 
flexed  position.  The  dorsal  region  participates  less  and  the  lumbar  region  more 
in  the  movement. 


Fig. 


-Side  Bending  in  the  Upright  Position  of  the  Cadaver,  showing  the  Same 
Characteristics  as  in  the  Model. 


Side  Bending  in  the  Hyperextended  Position  of  the  Spine. — With  the  spine 
of  the  cadaver,  model,  or  child  hyperextended,  the  side  bending  becomes  a 
sharply  limited  movement,  localized  low  down  in  the  spine  and  occurring  almost 
wholly  below  the  eleventh  dorsal  vertebra,  becoming  therefore,  essentially  a  lum- 
bar movement.  The  dorsal  region  bends  as  a  whole  upon  the  lumbar  and  rocks 
over  to  the  side  practically  unchanged,  being  locked  against  side  bending  by  the 
hyperextended  position. 

Side  bending,  therefore,  is  situated  highest  in  the  flexed  position,  lower  down 
in  the  erect  position,  and  lowest  in  hyperextension  in  the  model  cadaver,  and 
child. 

Rotation  Accompanying  Side  Bending  in  the  Hyperextended  Position. — This  is 
a  sharply  limited  movement   occurring  in  the  lumbar  region,   including  the 


36 


THE    MOVEMENTS    OF    THE    SPINE 


twelfth  dorsal  as  functionally  a  lumbar  vertebra.  The  thorax  rocks  over  to  the 
side  unchanged,  and  the  rotation  of  the  bodies  is  to  the  concave  side  of  the  lateral 
curve. 

Rotation  accompanj'ing  side  bending  is,  therefore,  of  a  different  type  in  the 
flexed  position  of  the  spine  from  what  it  is  in  the  erect  or  hyperextended  position. 

Illb.  ROTATION 

Rotation  or  twisting  of  the  spine  is  to  be  considered  as  part  of  a  compound 
movement  of  which  side  bending  forms  the  other  part.     For  purposes  of  simplicity 


Fig.  2S- — Side  Bending  to  the  Right  in  the  Hyperextended  Position  of  the  Spine 

IN  the  Model. 
The  head  is  supported  to  secure  steadiness. 


the  rotation  element  of  the  movement  will  be  considered  by  itself.  Under  or- 
dinary conditions  it  is  essentially  a  movement  of  the  dorsal  and  cervical  regions 
in  which  the  lumbar  vertebrae  take  but  little  part  except  in  hyperextension  and 
with  the  use  of  traction.  The  lumbar  vertebral  region  possesses  some  power  of 
rotation,  as  has  been  generally  observ^ed. 


ROTATION 


37 


Rotation  in  the  Erect  Position.^ — Rotation  is  freest  in  the  erect  position  and 
is  situated  in  the  cervical  and  dorsal  regions,  reaching  its  maximum  at  the  top 
of  the  cervical  column  and  extending  down  the  spine  to  the  lower  dorsal  region, 
where  it  disappears.  With  very  forcible  rotation  applied  to  the  top  of  the  column 
in  the  cadaver,  the  first  and  even  the  second  lumbar  vertebra  may  be  rotated. 
The  rotation  in  this  position  is  accompanied  by  a  side  bend  of  the  rotated  region 
away  from  the  side  to  which  the  bodies  of  the  vertebrae  turn.  If  the  rotation  is 
to  the  right,  it  is  accompanied  by  a  lateral  bend  convex  to  the  left  and  vice  versa. 
In  the  model  an  active  rotation  to  the  right  is  accompanied  by  a  displacement  of 
the  trunk  to  the  left  side  and  vice  versa.  If  trp,ction  is  applied  to  the  head  of  the 
erect  cadaver,  forcible  twisting  of  the  head  results  in  rotation  of  the  lumbar 
vertebras,  including  the  fourth. 


Fig.  26. — Side  Bending  to  the  Right  in 
Hyperextension  in  the  Column  of  Ver- 
tebral Bodies. 

The    same  characteristics   are  shown  as  in 
the  previous  figure. 


Fig.  27. — Side  Bending  to  the  Right 
in  the  Hyperextended  Position  of  the 
Spine  in  the  Cadaver. 

The  movement  occurs  chiefly  at  and  be- 
low the  dorsolumbar  junction,  and  the  bodies 
of  the  vertebrae  turn  to  the  right,  as  shown 
•  by  the  pins.  The  lateral  curve  is  convex  to 
the  left. 


Rotation  in  the  Flexed  Position.- — ^Rotation  in  the  flexed  position  of  the 
spine  occurs  chiefly  in  the  cervical  and  upper  dorsal  spine,  the  lower  dorsal  and 
lumbar  region  seeming  locked  against  rotating  forces  by  the  flexed  position.  The 
more  extreme  the  flexion  the  more  markedly  in  cadaver,  model,  and  child  is  the 
rotation  restricted  to  the  cervical  and  upper  dorsal  spine. 

Rotation  in  the  Hyperextended  Position. — In  hyperextended  positions 
rotation  with  moderate  manual  force  occurs  as  a  twisting  of  the  whole  thorax  on 
an  axis  in  the  dorsolumbar  region,  the  upper  and  middorsal  regions  apparently 
being  locked  against  rotation  by  hyperextension.     The  site  of  rotating  movement 


38 


THE    MOVEMENTS    OF    THE    SPINE 


in  this  position  is,  therefore,  in  the  one  or  two  vertebras  above  and  the  one  or  two 
vertebrae  below  the  dorsolumbar  junction. 

Rotation,  therefore,  is  located  high  in  flexed  positions,  lower  in  erect  positions, 
and  is  situated  lowest  and  is  more  sharplj^  localized,  in  hyperextended  positions. 

Side  Bends  Accompanying  Rolalion. — A  lateral  deviation  of  the  spine  accom- 
panies all  rotations.  It  is  situated  at  the  site  of  the  rotation  and  is  convex  to  the 
right  when  the  rotation  is  to  the  left  and  vice  versa.  In  the  erect  position  rotation 
causes  a  marked  side  curve  in  the  dorsal  region. 


Fig.  28. — •Rotation  of  the  Model,  Face  to  the  Right,  Causing  a  Dorsal  Lateral 
Curve  Convex  to  the  Left  and  a  Displacement  of  the  Trunk  to  the  Left. 


Reasons  for  Torsion. — It  is  obvious  from  these  experiments  that  there  must 
be  some  fundamental  reason  for  the  constant  occurrence  of  one  type  of  torsion 
for  side  bendings  in  flexion  and  the  occurrence  of  another  type  in  extension,  as 
well  as  for  the  constant  association  of  torsion  with  side  bending.  The  vertebral 
column  is  a  flexible  rod  capable  of  bearing  great  weight.  It  is  not  equally  flexible 
in  all  directions,  but  it  is,  of  course,  capable  of  some  movement  in  all  planes,  and, 
as  such,  should  come  under  the  control  of  the  laws  governing  flexible  rods  in 
general.     The  extent  of  any  of  the  movements  of  the  spine  is,  of  course,  greatly 


TORSION 


39 


influenced  by  the  shape  of  the  vertebral  bodies,  the  curves  of  the  spine,  the 
character  of  the  articular  processes,  the  resistance  of  the  ligaments,  and  the 
relative  strength  of  the  muscles. 

From  the  mechanical  point  of  view,  torsion  results  from  any  motion  of  a 
straight  flexible  rod  in  which  all  the  particles  do  not  move  in  parallel  planes. 
Consequently,  if  such  a  rod  is  bent  in  two  planes  at  the  same  time,  torsion  must 
inevitably  occur.  The  vertebral  column  is  not  a  straight  flexible  rod,  but  one 
bent  in  physiological  curves  in  the  antero-posterior  plane;  side  bending  must 
therefore  inevitably  lead  to  torsion,  because  it  means  bending  in  two  planes. 
Nor  does  the  fact  that  the  intervertebral  discs  permit  motion  in  all  directions 
affect  the  question,  because  from  a  mechanical  point  of  view  the  vertebral  column 
behaves  in  general  as  it  would  if  it  were  a  homogeneous,  flexible  rod. 


Fig.  29. — Rotation  of  the  Spine  of  the 
Cadaver,  Face  to  the  Right,  in  the 
Flexed  Position  of  the  Spine. 

The  movement  is  seen  to  be  located  in  the 
upper  part  of  the  column  by  the  deviation  of 
the  pins. 


Fig.  30. — Rotation  of  the  Spixe  of  the 
Cadaver,  Face  to  the  Right,  in  the  Hy- 
perextended  Position. 

The  movement  is  seen  to  occur  in  the 
lower  part  of  the  spine  by  the  rotation  of 
the  pins. 


A  strip  of  sponge  rubber,  half  an  inch  in  diameter  and  14  inches  long,  rotates 
in  the  same  way  that  the  vertebral  column  does  in  the  same  position.  A  lateral 
curvature,  in  what  corresponds  to  the  flexed  position  of  the  spine,  may  be  pro- 
duced in  the  rubber  strip  following  the  same  rule  of  rotation  seen  in  life;  that  is, 
the  front  of  the  rod  turns  toward  the  convexity  of  the  lateral  curve.  An  artificial 
lateral  curvature  in  the  rubber  strip,  made  in  what  corresponds  to  the  extended 
position  of  the  spine,  results  in  a  reverse  rotation  to  that  from  the  rotation  of  the 
flexed  position.  A  piece  of  rattan,  a  piece  of  rubber  tubing,  a  strip  of  sponge 
rubber,  round  or  square,  the  backbone  of  a  fish,  or  the  backbone  of  a  cat,  behave 
all  in  the  same  way,  and  rotate  in  the  same  direction  as  does  the  human  spine. 


40 


THE    MOVEMENTS    OF    THE    SPINE 


Articular  Processes. — Although  it  is  easy  to  understand  that  the  column 
of  vertebral  bodies  by  itself  might  easily  behave  as  a  flexible  rod,  yet  the  articular 
processes  cannot  be  left  out  of  account.  They  must  be  an  important  factor  in 
determining  torsion,  and  they  must  do  one  of  two  things.  Either  they  must  fall 
in  with  the  behavior  of  the  flexible  column  of  bodies  and  serve  to  carry  out  the 
rotation  which  would  occur  without  them,  or  they  must  obstruct  or  reverse  the 
rotation  which  would  occur  in  the  column  of  vertebral  bodies  alone.  Experiments 
seem  to  show  that  the  articular  processes  merely  serve  to  accentuate  the  same 

rotation  that  would  be  present  if  the 
column  of  vertebral  bodies  were  by 
itself. 

THE  CERVICAL  REGION 

Flexion. — It  is  possible  to 
straighten  the  anterior  phj'siological 
curve.  Much  of  the  apparent  for- 
ward flexion  in  the  cervical  region  in 
life  is  evidently  due  to  the  motion  be- 
tween the  occiput  and  the  atlas. 

H5T)erextension. — The  physiolog- 
ical curve  can  be  increased  to  a  cer- 
tain extent. 

Side  Bending. — Side  bending  is 
uniformly  distributed  throughout  the 
cervical  region  and  is  accompanied 
by  rotation  of  the  bodies  of  the  ver- 
tebra to  the  concavity  of  the  lateral 
curve,  as  in  the  lumbar  region. 

Rotation. — Rotation  is  extremely 
free  between  the  first  and  second 
cervical  vertebra,  but  for  the  rest  of 
the  region  it  is  limited.  Rotation  is 
accompanied  by  a  side  bend  convex 
to  the  side  opposite  to  which  the 
bodies  of  the  vertebras  turn;  that  is, 
in  a  right  rotation  the  curve  is  con- 
vex to  the  left. 


Fig.    31. — Diagram   of   the   Spin.al    Move- 
ments IN  A  Living  Child. — -(.Engelhard.) 
The  solid  line  shows  the  normal  position,  the 
dotted   line   the   forward  bend  and  the  line  of 
dots  and  dashes  the  hyperextended  position. 


DORSAL  REGION 

The  dorsal  region  is  the  least  mobile  part  of  the  spine  as  a  whole.  The  twelfth 
dorsal  vertebra  from  the  point  of  view  of  function  must  be  regarded  as  a  lumbar 
vertebra  and  not  as  part  of  the  dorsal  region. 

Flexion. — The  dorsal  spine  already  convex  backward  can  be  made  somewhat 
more  convex  by  forward  bending,  but  the  extent  of  the  movement  is  not  great  and 
by  no  means  comparable  to  the  same  movement  in  the  lumbar  region. 

Hyperextension. — Hyperextension  is  a  motion  of  very  slight  extent  in  the 
dorsal  region.  It  consists  of  a  diminution  of  the  backward  convexity  and  is  most 
noticeable  in  the  lower  half  of  the  region. 


CONCLUSIONS   AS    TO    MOVEMENTS  4I 

Side  Bending. — Side  bending  of  the  dorsal  region  is  a  fairly  evenly  distributed 
movement  of  slight  extent,  presenting  an  even  curve  which  is  greatest  in  the  mid- 
dorsal  region.  It  is  freest  in  the  erect  position  or  lying  on  the  face.  It  occurs 
less  markedly  in  flexed  positions  and  least  in  hyperextension.  Side  bending  in 
this  region  is  always  accompanied  by  rotation  of  the  bodies  of  the  vertebrae  to 
the  convex  side  of  the  lateral  curve. 

Rotation  is  the  most  marked  of  dorsal  movements.  It  reaches  its  greatest 
extent  in  the  upper  dorsal  vertebrae  and  diminishes  toward  the  lower  end  of  the 
region.  In  a  rotation  of  moderate  force  in  the  upright  position  it  extends  to  and 
includes  the  seventh  or  eighth  dorsal  vertebra.  Rotation  of  the  dorsal  region  is 
less  easily  accomplished  in  flexion  than  in  the  erect  position  and  in  hyperextension 
it  is  much  limited,  while  in  extreme  hyperextension  in  the  cadaver  the  dorsal 
rotation  movement  seems  to  be  obliterated. 

Rotation  is  accompanied  always  by  side  bending,  the  lateral  curve  being  convex 
to  the  side  away  from  which  the  bodies  of  the  vertebrae  turn.  In  a  rotation  of  the 
top  of  the  column  to  the  left  the  lateral  curve  is  to  the  right  and  vice  versa. 

The  practical  points  to  be  borne  in  mind  in  the  study  of  the  dorsal  region  are 
the  facts  that  rotation  is  freer  than  side  bending,  that  hyperextension  is  extremely 
limited,  and  that  the  region  on  the  whole  is  comparatively  immobile. 

LUMBAR  REGION 

Flexion  in  the  lumbar  region  is  a  movement  of  much  freedom,  but  the  physio- 
logical curve  in  the  adult  cadaver  has  not  been  obliterated  in  any  case  observed 
by  the  writer. 

H3qperextension  as  a  general  spinal  movement  is  essentially  a  lumbar  motion 
and  in  that  region  is  an  evenly  distributed  end. 

Side  bending  is  a  free  movement  in  the  lumbar  region  and  forms  in  the  erect 
position  a  very  evenly  distributed  curve;  it  is  greatest  in  the  erect  position  and 
least  in  extreme  flexion. 

The  rotation  accompanying  side  bending  in  the  lumbar  spine  is  always  with  the 
bodies  turning  to  the  concavity  of  the  lateral  curve,  which  is  to  be  contrasted 
with  the  opposite  rotation  occurring  in  side  bending  in  the  dorsal  region. 

Rotation  in  the  lumbar  region  is  extremely  limited  and  is  diminished  by  extreme 
hyperextension  and  is  least  or  absent  in  extreme  flexion.  The  lumbar  region 
possesses  marked  mobility  in  flexion,  hyperextension,  and  side  bending,  and  but 
little  in  rotation.  Side  bending  is  more  free  than  rotation  in  contradistinction 
to  the  relation  of  these  two  movements  in  the  dorsal  region. 

CERTAIN  CONCLUSIONS  AS  TO  THE  MOVEMENTS  OF  THE  THREE 
REGIONS  OF  THE  SPINE 

1.  In  the  lumbar  region  flexion  diminishes  mobilit}'  in  the  direction  of  side 
bending  and  rotation,  and  extreme  flexion  seems  to  lock  the  lumbar  spine  against 
these  movements. 

2.  In  the  dorsal  region  hj'perextension  diminishes  mobility  in  the  direction  of 
side  bending  and  rotation.  Extreme  hj'perextension  seems  to  lock  the  dorsal 
spine  against  these  movements. 

3.  In  flexion  of  the  whole  spine  side  bending  is  accompanied  by  rotation  of 


42  THE   MOVEMENTS    OF    THE    SPINE 

the  vertebral  bodies  to  the  convexity  of  the  lateral  curve,  the  characteristic  of  the 
dorsal  region. 

4.  In  the  erect  position  and  in  hyperextension  of  the  whole  spine  side  bending 
is  accompanied  by  rotation  of  the  vertebral  bodies  to  the  concavity  of  the  lateral 
curve,  the  characteristic  of  the  lumbar  region. 

5.  The  dorsal  region  rotates  more  easily  than  it  bends  to  the  side,  whereas 
the  lumbar  region  bends  to  the  side  more  easily  than  it  rotates. 

6.  Rotation  in  the  dorsal  region  is  accompanied  by  a  lateral  curve,  the  con- 
vexity of  which  is  opposite  to  the  side  to  which  the  bodies  of  the  vertebrae  rotate. 

These  conclusions  are  true  of  the  normal  spine,  but  they  do  not  necessarily 
apply  to  a  deformed  scoliotic  spine.  The  nearer  a  scoliotic  spine  approaches  the 
normal,  the  more  likely  are  they  to  apply  without  modification. 


CHAPTER  IV 
MECHANISM  OF  SCOLIOSIS 

The  Mechanics  of  the  Upright  Position  (Balance). — The  spine 
is  a  curved,  segmented,  weight-bearing  rod  resting  in  unstable 
equilibrium  on  the  sacrum,  which  forms  part  of  a  bony  ring  balanced 
on  the  hip-joints.  Its  upright  position  is  due  to  a  sense  of  balance 
possessed  by  the  living  individual,  for  if  the  cadaver  is  placed  in  the 
upright  position  it  falls  on  account' of  the  absence  of  muscular  ac- 
tion. This  sense  of  balance  expresses  itself  in  a  muscular  contrac- 
tion by  which  the  living  individual  keeps  his  center  of  gravity  over 
the  center  of  support.  It  is  reflex  and  instinctive,  and  the  individual 
has  no  knowledge  of  it  as  such,  any  more  than  he  has  of  the  mechan- 
ism of  breathing  or  swallowing. 

The  living  individual,  therefore,  keeps  his  spine  erect,  first,  because 
he  has  a  sense  of  balance,  and  second,  because  he  has  a  muscular 
system  which  responds  to  his  instinctive  nervous  impulses  and 
carries  out  of  itself  the  necessary  muscular  adjustment  which  is  too 
complicated  to  describe  or  formulate.  This  instinctive  sense  of 
balance  and  equilibrium  must  be  regarded  as  an  attribute  of  the 
erect  living  individual,  and  must  be  given  a  place  in  the  study  of 
scoliosis.     It  is  effective  in  two  directions: 

1.  The  erect  person  instinctively  strives  to  keep  the  head  approxi- 
mately over  the  middle  of  the  pelvis,  that  is,  in  the  sagittal  or  antero- 
posterior median  plane  of  the  body. 

2.  The  erect  person  instinctively  strives  to  keep  the  face  to  the 
front  and  the  shoulder-girdle  approximately  in  the  same  plane  as 
the  pelvis,  i.e.,  in  the  frontal  or  lateral  plane  of  the  body. 

This  adjustment,  especially  the  element  which  seeks  to  keep  the 
shoulder-girdle  in  the  same  plane  as  the  pelvis  while  disturbances 
twisting  the  column  below  are  taking  place,  is  an  important  factor 
in  explaining  the  phenomena  of  scoliosis,  as  will  be  seen  later. 

The  body  is,  however,  not  a  firm  mass,  but  consists  of  segments 
joined  together,  one  segment  resting  upon  the  other,  and  firmly 
connected  by  a  tube  made  up  of  muscles,  fasciae,  and  integument.^ 
Since  to  maintain  the  erect  attitude  the  line  of  gravity  must  pass 

^  Feiss:  "Amer.  Jour.  Orth.  Surg.,"  iv,  i,  37. 

43 


44 


MECHANISM   OF    SCOLIOSIS 


■J' 


through  the  base  of  support,  so  in  all  positions  in  which  balance 
is  maintained  there  is  a  constant  equilibration  by  means  of  shifting 
segments. 

It  is  necessary  at  this  place  to  introduce  certain  elementary  points 
in  mechanics  which  are  familiar  to  every  one. 
These  points  are  the  following: 

I.  The  base  of  support  of  the  upright  human  figure  consists  of  a 
trapezoid  formed  by  the  outer  borders  of  the  feet  and  lines  connect- 
ing the  back  of  the  heels  and 
.n.  I      the  front  of  the  toes. 

j^^     .lOliik.  I  2.  The  center  of  support  lies 

^^B>~'  ■  j      perpendicularly  under  the  cen- 

,  ^      ter  of  gravity  and  in  the  erect 

position  must  always  lie  within 
i      this  trapezoid. 
""•-  "":  i>  3.  For  the  purpose  of  study- 

ing the  mechanism  by  which 
any  weight  is  borne  by  a  solid 
body  in  unstable  equilibrium, 
the  entire  weight  may  be  re- 
garded as  concentrated  in  the 
center  of  gravity,  and  the  de- 
termination of  the  relation  be- 
tween the  center  of  gravity  and 
the  bearing  points  determines 
the'lines  of  stress. 

The  Defects  of  the  Upright 
Position. — An  important  mat- 
ter in  the  mechanics  of  the 
spine  and  its  appendages  is  that  it  is  evolved  with  comparatively 
slight  modifications  from  the  quadruped  spine,  and,  in  fact,  is 
hardly  more  than  the  quadruped  spine  set  upright.  In  the 
quadruped  the  spine  is  a  horizontal  sustaining  structure  arched 
upward,  supported  at  one  end  by  two  anterior  limbs  and  at  the 
other  by  two  posterior  limbs;  the  viscera  hang  directly  down 
from  this,  being  supported  by  ligaments  and  attachments  at  right 
angles  to  the  supporting  structure.  On  account  of  the  angle  of  the 
ribs  the  thoracic  cavity  is  helped  in  inspiration  by  gravity  as.  the 
ribs  fall  into  the  position  of  thoracic  expansion,  but  they  must  be 
pulled  up  to  contract  the  thorax;  and,  finally,  equilibrium  is  much 
more  easily  maintained  than  in  the  biped,  because  the  supporting 


Fig.  32. — The  Right  Side  of  the  Pelvis 
OF  THE  Cadaver  is  Raised  and  the  Upper 
Part  of  the  Spine  Falls  to  the  Left, 
Making  a  Lateral  Curve  Convex  to  the 
Right. 


MECHANISM   OF    SCOLIOSIS  45 

base  is  broad  and  the  weight  of  the  mass  to  be  supported  is  compara- 
tively small. 

When  this  structure  with  only  comparatively  slight  modifications 
is  set  on  end  and  made  to  fulfil  the  functions  of  a  weight-bearing 
column  in  a  plane  at  right  angles  to  that  for  which  it  is  best  adapted, 
certain  unfavorable  factors  are  introduced  which  serve  as  distinct 


Fig.  33. — The  Right  Side  of  the  Pelvis  of  the  Model  is  Raised  and  the  Upper 
Part  of  the  Spine  is  Carried  to  the  Right,  Making  a  Lateral  Curve  Convex  to 
theJLeft.     (Cf.  Fig.  44.) 

limitations.  The  column  constructed  to  bear  weight  and  sustain 
strain  at  right  angles  to  its  long  axis  must  now  bear  weight  and  sus- 
tain strain  in  its  long  axis.  The  two  anterior  limbs,  which  formerly 
served  as  props,  now  hang  as  dead  weights  to  be  supported  by  the 
column.  To  maintain  equilibrium  much  greater  muscular  effort 
is  necessary  to  maintain  functional  balance  in  the  man  than  in  the 
quadruped.     The  viscera  hang  no  longer  at  right  angles  to  the  sup- 


46  MECHANISM    OF    SCOLIOSIS 

porting  structure,  but  in  the  line  of  its  long  axis.  The  thorax  to 
expand  has  to  raise  all  the  ribs  and  work  against  gravity. 

But  what  is  most  important  in  the  present  connection  is  the  fact 
that  the  upright  position  is  decidedly  hard  to  maintain,  because  the 
base  of  support  is  so  small  and  the  height  of  structure  to  be  supported 
is  relatively  so  great. 

This  structure  from  a  mechanical  point  of  view  consists  of  two 
vertical  legs  attached  to  a  horizontal  pelvis  in  the  middle  of  which  is 
set  an  upright  column  expanding  into  a  bony  cage  carrying  the  weight 
of  arms,  head,  and  thoracic  contents.  All  the  weight  comes  down 
through  a  single  column,  the  lumbar  region  of  the  spine,  which 
column  rests  upon  the  middle  of  the  pelvis.  Such  a  structure  is 
one  necessarily  susceptible  to  disturbances  of  balance,  and  it  will 
yield  to  such  disturbances  by  assuming  abnormal  curves  either 
lateral  or  antero-posterior. 

Relation  of  Balance  to  Curves. — If  the  pelvis  of  a  cadaver  is  raised 
on  the  right  side  and  the  upright  spine  is  left  free  to  move,  the  top 
of  the  column  falls  to  the  left  and  the  spine  is  curved  convex  to  the 
right.  This  is  the  position  induced  by  gravity.  If,  on  the  other 
hand,  the  right  side  of  the  pelvis  of  a  living  model  is  raised  and  the 
upright  spine  is  left  free  to  move,  the  top  of  the  column  remains 
upright  and  the  spine  is  curved  in  the  opposite  direction,  convex  to 
the  left.  This  is  the  position  of  balance  overcoming  the  position 
induced  by  gravity.  The  sense  of  equilibrium  has  worked  against 
the  force  of  gravity  and  has  reversed  the  position  natural  to  the 
cadaver. 

Anything  which  causes  any  part  of  the  body  to  be  held  in  an 
asymmetrical  position  will  cause  a  lateral  deviation  of  some  part 
of  the  spine,  because  a  straight  erect  spine  in  the  sagittal  plane  is 
possible  only  when  the  person  stands  on  both  feet  or  sits  erect 
with  the  arms  in  similar  positions  and  the  head  pointing  straight 
ahead.  Every  step,  every  raising  of  the  arm,  every  tilting  of  the 
head  is  accompanied  by  a  deviation  of  the  spine  from  the  median 
plane  of  the  body:  in  other  words,  by  a  temporary  lateral  curve 
which  disappears  as  the  symmetrical  attitude  is  resumed. 

If  there  is  a  visual  error  that  causes  the  head  to  be  held  obliquely; 
if  there  is  a  short  leg  causing  the  pelvis  to  be  no  longer  horizontal  but 
slanted;  if  the  muscles  of  one  side  of  the  back  are  paralyzed;  there 
must  be  a  constant  compensation  or  curve  which  will  still  enable  the 
center  of  gravity  to  be  held  over  the  center  of  support.  When  such 
a  curved  position  becomes  habitual  for  any  of  the  reasons  given  or 


PLASTICITY    OF    BONE 


47 


for  other  reasons,  there  exists  in  the  adaptive  character  of  bone  a 
reason  why  this  constantly  assumed  malposition  should  make  a 
change  in  the  shape  of  the  bones  in  a  growing  child  and  that  these 
changes  should  become  fixed. 

Plasticity  of  Bone. — The  adaptability  of  bone  to  pressure  has  been 
recognized  in  general,  and  has  been  formulated  and  forms  one  aspect 
of  what  is  often  spoken  of  as  Wolff's^  law, 
which  may  be  expressed  briefly  as  follows: 
"Every  change  in  the  formation  and  function 
of  the  bones,  or  of  their  function  alone,  is 
followed  by  certain  definite  changes  in  their 
internal  architecture  and  equally  definite  sec- 
ondary alterations  of  their  external  confor- 
mation in  accordance  with  mathematical 
laws." 

The  phenomena  of  lateral  curvature  have 
become  somewhat  more  comprehensible  since 
we  have  understood  that  bone  is  a  plastic  and 
adaptable  structure,  adapting  itself  to  the 
demands  on  it,  following  in  its  growth  the 
lines  of  least  resistance,  and  in  children  sus- 
ceptible to  great  changes  in  shape  from  abnor- 


FiG.  34. — Experimental 
Scoliosis  in  a  Rabbit 
Produced  by  Cutting  the 
Erector  Spin^  Muscles. 
— {Arndt.) 


Fig.  35. — Fifth  Lumbar  Vertebra 
FROM  Experimental  Scoliosis  in 
Rabbit.  — {Arndt.) 


mal    conditions.     As  an  instance  of  this  may  be  mentioned  the 

great  distortion  of  the  shape  of  the  bones  in  the  Chinese  lady's  foot 

produced  by  bandaging.     It  is  not  necessary  to  multiply  them,  for 

we  have  direct  experimental  proof  of  the  case  in  question  in  the 

experiments  of  Wullstein  and  Arndt. 

1  Wolff:  "Das  Gesetz  der  Transformation  der  Knochen,"  Berlin,  1892; 
Freiberg:  "Am.  Jour.  Med.  Sci.,"  Dec,  1902;  "Animal  Mechanics,"  by  Sir 
Charles  Bell  and  J.  Wyman,  Cambridge,  1902. 


48  MECHANISM   OF    SCOLIOSIS 

Wullstein^  showed,  by  bandaging  young  dogs  for  months  in  posi- 
tions with  the  spine  bent  laterally  in  some  and  in  others  bent  back- 
ward, that  a  permanent  bony  deformity  occurred  which  could  not  be 
removed  by  traction  in  the  length  of  the  spine  after  death.  A  sec- 
tion of  these  columns  showed  wedge-shaped  deformity  of  the  verte- 
brae with  a  "lipping"  or  overgrowth  of  the  borders  of  the  vertebrae  on 
the  concave  side  of  the  curve,  the  trabeculae  being  thickened  on  the 
side  of  the  bodies  toward  the  concavity.  The  changes  were  more 
marked  at  the  articular  ends  of  the  bones  than  in  the  middle  of  them. 

Arndt^  produced  similar  permanent  curves,  characterized  by  bony 
deformity  and  marked  rotation,  in  rabbits  by  extirpation  of  the  erec- 
tor trunci  muscles  on  one  side.  They  showed,  as  in  Wullstein's  ex- 
periments, that  the  changes  are  greatest  at  the  articular  ends  of  the 
bodies,  and  the  epiphyseal  plates  in  the  most  deformed  vertebrae 
clearly  overlap  the  sides  of  the  body. 

The  point  to  be  remembered  is,  that  the  erect  position  is  a  singu- 
larly unstable  one  and  temporary  lateral  deviation  of  the  spine  occurs 
in  almost  every  movement  of  the  body.  If  such  deviation  becomes 
permanent  for  any  reason,  it  must  further  be  remembered  that  grow- 
ing bone  is  a  plastic  structure  and  that  the  spine  will  tend  to  conform 
its  bony  shape  to  the  abnormal  position.  Here  then,  exists  the 
mechanism  for  the  acquiring  of  bony  lateral  curvature  if  sufficiently 
long  continued.  There  are,  of  course,  many  other  causes  of  lateral 
curvature  which  will  be  mentioned. 

TYPES  OF  LATERAL  CURVATURE 

There  are  two  types  of  malposition  commonly  described  as  lateral 
curvature  or  scoliosis.  This  is  unfortunate  and  leads  to  misunder- 
standing and  confusion.  In  one,  the  position  is  that  which  any 
normal  spine  may  assume;  in  the  second,  the  position  is. one  that  the 
normal  spine  cannot  assume,  a  position  which  implies  a  change  in 
the  shape  of  the  bones. 

It  would  add  much  to  a  better  understanding  of  the  subject  if  the 
former  were  called  faulty  attitude  or  some  similar  name,  and  the 
term  scoliosis  were  reserved  for  the  latter  form. 

The  first  is  due  to  the  adjustment  necessary  to  keep  the  balance  of 
the  spine  in  the  presence  of  one  of  the  disturbing  causes  mentioned. 
If  this  becomes  habitual,  it  results  in  a  typical  attitude  to  be  de- 
scribed as  total  or  postural  lateral  curvature  in  the  chapter  on  Descrip- 

1  "Zeitsch.  f.  orth.  Chir.,"  x,  2. 

2  "Archiv  f.  orth.  Chir.,"  i,  i,  2. 


BONY   ROTATION 


49 


tion  and  Symptoms.     This-  attitude  may  persist  as  such  or  change 
to  the  second  form  to  be  described  next. 

The  second  type  of  lateral  curva- 
ture is  accompanied  by  a  change  in 
the  shape  of  the  bones  and  soft  parts. 
It  cannot  be  reproduced  experiment- 
ally in  the  model,  cadaver,  or  child, 
and  is  not  within  the  physiological 
limits  of  the  spine.  It  must,  there- 
fore, be  classed  as  structural  or  organic 
lateral  curvature.  The  characteristic 
feature  is  a  local  backward  prominence 
of  the  ribs  or  lumbar  transverse  proc- 
esses in  the  curved  region,  which  is 
called  ''bony  rotation." 

Bony  Rotation. — The  reason  that 
bony  rotation  or  twisting  of  the  verte- 
bral bodies  always  accompanies  or- 
ganic lateral  curvature  has  been  widely 
discussed  from  every  point  of  view,  and 
the  question  has  been  much  compli- 
cated by  the  abstruse  reasoning  applied 
to  its  solution.  The  facts  seem  to  be 
these:  the  vertebral  column  is  a  flexible 
weight-bearing  rod  curved  in  the  an- 
tero-posterior  plane  by  the  physiolog- 
ical curves:  in  a  column  affected  by 
lateral  curvature  it  is  now  beginning 
to  be  curved  to  one  side  in  some  part  of 
its  length.  Growing  bone,  it  has  been 
stated,  is  a  plastic  structure  and  will 
yield  to  unequal  conditions  of  weight 
or  strain.  This  curved  part  of  the 
column  being  subject  to  unequal  con- 
ditions of  weight  on  the  two  sides 
tends  to  yield  to  the  side  and  to 
change  its  structure  in  accordance  with  these  unequal  conditions 
of  weight. 

But  a  plastic  weight-bearing  column  already  curved  in  one  plane 
cannot  yield  in  another  plane  (i.e.,  to  the  side)  without  twisting,  and 
in  this  twist  the  vertebrse  can  turn  in  only  one  way,  namely,  away 
4 


Fig.  36. — Experimental  Scoli- 
osis IN  A  Young  Dog  Produced 
BY  Bandaging  in  a  One-sided  Posi- 
tion.— {WuUstein.) 


50  MECHANISM    OF    SCOLIOSIS 

from  the  greatest  weight  and  pressure,  which  is,  of  course,  on  the 
concave  side  of  the  lateral  curve.  If  they  were  to  turn  toward  the 
middle  line  instead  of  away  from  it  they  would  encounter  the  greater 
instead  of  the  less  resistance  and  have  to  raise  the  whole  weight  of  the 
parts  above  them.  In  so  far  as  they  are  plastic  they  will  be  com- 
pressed where  the  weight  is  greatest  or  on  the  concave  side.  The 
deformity  of  the  vertebras  is  therefore  due  to  their  plasticity  yielding 
to  conditions  of  uneqiial  strain,  and  turning  where  they  must  turn 
to  escape. 

Double  Curves. — The  explanation  of  a  double  curve  is  more  diffi- 
cult. It  has  been  observed  that  frequently  a  double  organic  curve 
grows  out  of  a  single  functional  one,  the  reason  for  which  will  be 
explained  in  the  chapter  on  Description  and  Symptoms.  It  cannot 
be  said  that  every  case  of  organic  double  curve  has  first  been  a  single 
postural  one,  for  congenital,  early  rachitic,  and  other  cases  make  that 
unlikely,  but  the  mechanism  is  present  for  forming  double  curves 
from  single  ones  under  the  influence  of  existing  conditions.  The 
occurrence  of  bony  change  in  some  cases  and  the  persistence  of  func- 
tional curves  in  others  can  only  be  explained  by  assuming  a  plasticity 
of  the  bones  in  certain  individuals  which  does  not  exist  in  the  bones 
of  others. 

The  chain  of  events  in  the  cases  where  a  single  curve  changes  to 
a  double  one  is  then,  first,  a  disturbance  of  the  symmetry  of  the  body 
and  the  appearance  of  a  functional  curve;  second,  the  persistence  of 
this  curve  from  the  same  causes  that  started  it,  the  phenomena  being 
still  within  the  normal  mechanism  of  the  spine;  third,  the  yielding  of 
plastic  vertebrae  in  the  line  of  least  resistance  and  the  appearance  of 
rotation  on  the  convex  side  of  the  lateral  curve;  fourth,  the  formation 
of  double  curves  from  single  ones  by  the  normal  mechanism  of  the 
spine  originating  in  the  sense  of  balance  and  adjustment.  It  seems 
that  in  many  cases,  perhaps  the  majority,  these  steps  cannot  be 
traced,  but  coincide  in  time. 


CHAPTER  V 
DESCRIPTION  AND  SYMPTOMS 

SYNONYMS 

English:  Scoliosis,  lateral  curvature  of  the  spine,  rotary  lateral 
curvature  of  the  spine. 

German:  Skoliose,  seithche  Riickgratsverkrlimmung,  Kypho- 
skoliose. 

French:  Scoliose,  deviation  laterale  de  la  taille. 

Italian:  Scoliose. 

Scoliosis,  or  lateral  curvature  of  the  spine,  is  the  name  applied  to  a 
condition  in  which  any  series  of  vertebral  spinous  processes  shows  a 
constant  deviation  from  the  median  line  of  the  body,  a  deviation 
always  accompanied  by  an  element  of  twisting.  In  certain  rare  cases 
the  twisting  may  be  the  predominant  appearance.  Deviation  of  a 
single  vertebra  from  the  median  line  does  not  constitute  scoliosis. 

Although  scoliosis  is  generally  studied  and  classified  as  a  deformity 
of  the  spine,  the  laws  of  equilibrium  of  the  body  are  such  that  any 
deviation  of  the  vertebral  column  must  disturb  the  whole  balance  of 
the  body,  and  scoliosis  is,  therefore,  accompanied  by  compensating 
lateral  displacement  of  the  pelvis  and  legs.  In  this  wider  sense 
scoliosis  is  to  be  regarded  as  a  deformity  of  the  whole  body,  espe- 
cially manifest  in  the  spine. 

Lateral  curvature  of  the  spine  is  necessarily  accompanied  by  a 
distortion  of  the  symmetry  of  the  body  for  which  the  patient  or  her 
parents  seek  advice.  It  is  not  generally  recognized  by  the  laity  as  a 
spinal  distortion,  but  the  patient  is  brought  for  surgical  advice 
because  of  "a  high  shoulder,"  "a  prominent  hip,"  or  "a  projecting 
shoulder-blade."  Very  often  the  dressmaker  is  the  first  to  recog- 
nize it  because  she  finds  that  she  must  make  the  skirt  longer  on  one 
side  than  on  the  other,  or  because  the  distance  from  the  armhole  to 
the  waistband  is  longer  on  one  side  than  on  the  other. 

The  condition  is  essentially  a  distortion,  and  symptoms  other  than 
the  deformity  are  rather  unusual  in  average  cases.  Occasionally  the 
patient  complains  of  feeling  "one-sided,"  but  this  is  rare.  Pain  is 
generally  not  complained  of,  but  in  neurasthenic  young  women, 

51 


52  DESCRIPTION   AND    SYMPTOMS 

especially  with  functional  curves,  backache  may  be  felt  more  or  less 
on  standing.  Pain  in  the  severer  cases  is  caused  by  the  descent  of  the 
ribs  to  the  level  of  the  crest  of  the  ilium  against  which  the  lower  ribs 
may  rub,  and  severe  local  pain  may  be  felt.  In  other  severe  cases, 
nerve-root  pressure  may  result  from  the  distortion  and  be  referred  to 
the  peripheral  ends  of  the  spinal  nerves. 

The  shortening  of  the  trunk  and  the  diminished  capacity  and  im- 
mobility of  the  thorax  may  lead  to  impairnient  of  the  function  of 
thoracic  and  abdominal  organs,  especially  in  severe  cases,  and  short- 
ness of  breath  is  common  in  such  cases  on  account  of  diminished 
respiratory  capacity.  Displacement  of  the  heart  and  phthisis  fre- 
quently occur  in  severe  cases  during  adult  life.  Disturbances  of 
digestion  are  also  frequent  from  displacement  of  the  stomach  and 
liver.  Impairment  of  vigor  and  of  the  general  health  generally 
result  in  severe  cases  in  adult  life,  although  children  with  severe 
curves,  as  a  rule,  suffer  less  deterioration  of  the  general  condition. 

It  is  not  uncommon  for  patients  to  go  through  life  with  curves  of 
moderate  degree  which  have  given  rise  to  little  or  no  trouble;  but 
at  or  after  middle  life,  when  atrophy  of  the  intervertebral  discs  has 
occurred,  such  curves  may  increase  and  give  rise  to  a  sense  of  asym- 
metry or  to  pain  in  the  back  or  at  nerve  terminations.  It  can  gen- 
erally be  predicted  that  a  curve  of  moderate  severity  may  be  more 
troublesome  in  later  adult  life. 

TERMINOLOGY 

The  terms  used  in  describing  lateral  curvature  must  be  defined. 
Curves  are  named  right  or  left  according  to  their  convexities,  curves 
convex  to  the  right  being  called  right  curves,  and  vice  versa.  In  addi- 
tion to  the  terms  right  or  left,  the  curves  are  named  also  according  to 
the  anatomical  region  involved  in  the  curves.  If  a  deviation  involves 
the  whole  spine,  it  is  called  a  total  curve;  all  other  curves  are  called 
cervical,  dorsal,  or  lumbar,  according  to  the  region  involved,  with 
the  qualifying  adjective  right  or  left  preceding  the  anatomical  name. 
If  a  curve  involves  more  than  one  region,  it  is  classed  as  cervicodorsal 
or  dorsolumbar.  If  two  curves  exist,  the  upper  curve  is  spoken  of 
first  and  the  lower  follows,  e.g.,  right  cervicodorsal,  left  dorsolumbar; 
or  right  dorsal,  left  lumbar. 

It  is  important  that  the  anatomical  region  affected  by  the  curve  be 
designated  accurately  and  not  loosely.  For  this  purpose  the  seventh 
cervical  and  last  lumbar  vertebral  spines  are  marked  on  the  skin  and 


FUNCTIONAL    SCOLIOSIS  53 

connected  by  a  string  representing  the  long  axis  of  the  spine.  Parts 
of  the  spine  lying  to  the  right  of  this  line  are  to  be  classified  as  right 
curves,  parts  to  the  left  as  left  curves.  Such  curves  must  be  assumed 
to  begin  and  end  where  they  pass  under  this  string.  For  example,  if 
the  spine  from  the  seventh  cervical  to  the  twelfth  dorsal  is  to  the  right 
of  the  line  arid  below  it  is  to  the  left,  it  is  a  right-dorsal,  left-lumbar 
curve.  If  the  spine  from  the  fourth  dorsal  to  the  third  lumbar  is  to 
the  right  of  the  line,  it  is  a  right  dorsolumbar  curve. 

This,  therefore,  provides  for  a  simple  rule  for  the  naming  of  every 
curve,  insisting  on  the  fact  that  the  location  of  the  upper  end  of  the 
column  has  nothing  to  do  with  the  naming  of  the  curve.  The  upper 
end  of  the  spine  may  be  in  the  median  plane  or  at  either  side  of  it, 
without  affecting  in  any  way  the  recognition  and  description  of  the 
spinal  curves. 

The  classification  of  curves  into  primary  and  secondary,  or  com- 
pensatory, is  not  of  great  importance,  nor  is  it  sound,  as  one  cannot 
always  say  which  curve  was  really  primary.  Often  it  is  obvious  that 
one  curve  is  predominant  and  evidently  the  one  to  be  attacked  in 
treatment.  In  other  cases  this  cannot  be  done,  as  the  curves  are  of 
equal  degree  and  importance  so  far  as  can  be  seen.  It  is,  however,  of 
importance  to  recognize  the  predominant  curve  where  possible.  For 
example,  in  a  marked  and  predominant  right  dorsal  curve  it  matters 
but  little,  practically,  whether  a  slight  lumbar  curve  exists  or  not;  for 
purposes  of  treatment  the  case  is  a  dorsal  curve.  In  general,  rational 
treatment  must  eliminate  unimportant  factors  and  deal  with  the 
salient  ones. 

The  former  division  of  lateral  curvature  into  stages  has  no  rational 
basis..  It  is  a  progressive  affection  passing  over  only  one  sharp  line, 
the  transition  from  postural  or  functional,  curves  to  structural  or 
organic  ones.  This  classification  of  functional  and  structural  will, 
therefore,  be  adopted  here  with  slight  emphasis  on  a  certain  puzzling 
type  of  cases  evidently  in  the  transitional  stage  from  the  functional 
tothe  structural  type. 

FUNCTIONAL  SCOLIOSIS  (TOTAL,  POSTURAL,  OR  FALSE 

SCOLIOSIS) 

The  term  "  total  scoliosis"  is  applied  to  cases  where  the  spine  forms 
one  gradual  curve  to  one  side  without  compensatory  curves.  In  90 
per  cent,  of  such  cases  the  curve  is  to  the  left.  According  to  the 
figures  of  Scholder  and  at  the  Children's  Hospital  clinic,  right  total 


54 


DESCRIPTION   AND    SYMPTOMS 


scoliosis  is  very  rarely  seen,  while  the  left  curve  is  very  common. 
The  greatest  point  of  deviation,  ^.f.,  the  apex  of  the  curve,  is  generally 
found  at  the  ninth  or  tenth  dorsal  vertebra,  but  it  may  be  found  in 
any  part  of  the  lower  half  of  the  dorsal  or  upper  half  of  the  lumbar 
region. 

In  frequency  of  occurrence  total  scoliosis  stands  in  the  fourth 
place  in  the  records  of  the  institute  of  Llining  and  Schulthess,  where 

patients  came  for  treatment, 
forming  but  15.39  Pe^"  cent,  of 
the  entire  number  of  lateral 
curvatures.  As  to  sex,  the  per- 
centage shown  in  these  cases  is 
24  for  males  and  17  for  females 
(Figs.  37  and  38).  In  boys  the 
number  of  total  scolioses  in- 
creases steadily  with  age,  but 
in  girls  a  decrease  is  noted  after 


Fig.  37. — Left  Total  Curve. 


Fig.  38.— Left  Total  Curve  Bent  For- 
w^ARD,  Showing  Prominence  of  Back  on 
THE  Right. 


the  twelfth  year,  coinciding  with  an  increase  in  the  number  of  left 
lumbar  curves.  Total  scoliosis  is  found  between  the  ages  of  five 
and  eighteen  years,  as  a  rule. 

The  deviation  at  the  greatest  curve  is  not  often  over  an  inch  and  a 
half  from  the  median  line  of  the  body.  There  is  no  obvious  compen- 
satory curve,  and  the  untrained  eye  is  likely  to  find  slight  cases 
normal.  There  is,  however,  a  perceptible  displacement  of  the  trunk 
to  the  left,  especially  as  seen  from  the  front,  and  a  plumb-line  sus- 
pended in  the  median  line  of  the  body  as  defined  by  the  vertical  fold 


FUNCTIONAL    SCOLIOSIS  55 

between  the  buttocks,  will  detect  a  decided  deviation  of  the  marked 
spines  from  the  median  plane.  The  typical  characteristics  of  a  left 
total  scoliosis  are  as  follows:  (i)  ^  general  curve  convex  to  the  left; 
(2)  the  left  shoulder  is  elevated;  (3)  the  right  side  of  the  shoulder-girdle 
is  carried  back  and  the  left  side  forward;  (4)  when  the  patient  bends 
forward  the  right  side  of  the  back  may  be  slightly  higher  than  the  left. 
Any  case  which  simulates  a  left  total  curve  and  in  which  these  signs 
are  not  all  present  should  be  subjected  to  the  closest  examination  and 
will  probably  be  found  to  be  transitional  in  character.  Functional 
curves  disappear  on  suspension  or  recumbency,  and  side  flexibility 
is  but  little  limited,  bending  to  the  left  being  often  somewhat  re- 
stricted.    In  cases  of  right  curves  the  description  is  reversed. 


): 


Fig.  39. — Left  Total  Curve.     The  Patient  from  which  Radiogram  was  Taken. 

The  changed  relation  of  the  shoulders  to  the  pelvis  is  more  evi- 
dent in  children  with  marked  lumbar  physiological  curves  than  in 
cases   with  round   backs. ^ 

The  position  in  a  typical  functional  total  curve  is  merely  the  physio- 
logical one  necessitated  in  every  normal  spine  for  any  reason  made 
convex  to  the  left,  and  can  be  produced  experimentally  by  putting  a 
book  under  the  right  foot,  which  raises  the  right  side  of  the  pelvis  and 
necessitates  for  balance  a  left  convex  curve  of  the  spine.  A  spine 
making  any  bend  convex  to  the  left  in  the  erect  position  will  turn  at 
its  upper  end  to  the  right,  as  explained  in  the  movements  of  the  spine. 
The  thorax  and  shoulders  will  be  twisted  backward  on  the  right,  and 

^  Schulthess:  "Zeitsch.  f.  orth.  Chir.,"  vi,  399-566,  1902. 


56 


DESCRIPTION   AND    SYMPTOMS 


when  the  patient  bends  forward,  this  twisted  position  of  the  shoulders 
may  be  carried  over  into  the  position  of  forward  bending,  if  the  case 
has  been  of  long  standing,  and  the  right  side  of  the  back  will  be  higher 


Fig.  40. — Radiogram  of  Total  Curve  in  Patient  Shown  in  Fig.  39. 

in    this    position.     This    "reverse    rotation,"    "concave    torsion," 
"retrotorsion,"  as  it  has  been  called,  has  been  much  discussed^  and  is 
1  Schulthess:  "Zeitsch.  f.  orth.  Chir.,"  x,  page  489. 


TRANSITIONAL    CURVES 


57 


an  accompaniment  of  total  scoliosis,  but  it  is  a  physiological  matter 
easily  understood  by  studying  the  mechanics  of  the  normal  spine. 
It 'has  been  claimed  that  total  scoliosis  is  really  a  triple-compound 

curve,  ^  and  that  the  torsion  to 
the  concave  side  is  really  due 
to  a  slight  right  dorsal  curve; 
n;-rays  of  such  cases  taken  in 
the  standing  position  show, 
however,  in  many  cases,  a  grad- 
ual curve  to  the  left  without 
compensating  curves  (Fig.  40); 
in  other  cases  apparently  total 
curves  in  a;-rays  taken  in  this 
way  seem  to  be  transitional 
cases. 


Fig.  41. — ^Case  of  "Paradoxical  Dor- 
soLUMBAR  Scoliosis"  Figured  by  Wilbou- 
CHEWITCH.      (Compare  Figs.  37-39.) 


Fig.  42. — Same  Case  as  in  Fig.  47 
Bent  Forward  Showing  Prominence 
OF  Ribs  on  Right  Side  with  Left 
Curve. — {Wilbouchewitch.) 


TRANSITIONAL  CURVES 

In  many  cases  which  on  first  inspection  appear  to  be  postural  more 
careful  examination  will  show  that  the  curve  is  obviously  changing 
from  the  postural  to  the  structural  type,  i.e.,  is  beginning  to  show 
changes  in  structure. 

In  such  transitional  cases  the  upper  part  of  the  spine  is  less  curved 
than  the  lower,  and  one  or  more  of  the  characteristic  signs  of  postural 
curves  are  most  often  wanting.  For  example,  the  right  shoulder  may 
be  elevated  in  a  left  curve,  or  the  left  side  of  the  back  may  be  promi- 
nent upward  in  forward  bending,  or  the  left  shoulder  may  be  carried 
forward.  Such  cases  must,  of  course,  be  recognized  as  early  struc- 
tural cases,  but  are  so  nearly  postural  that  they  may  be  wrongly 


^Reiner  and  WerndorfE:  "Verhandl.  Deut.  Gesel.  f.  orth.  Chir.,"  1906,  page 
232, 


58  DESCRIPTION    AND    SYMPTOMS 

classed  unless  identified.  It  is  not  exceptional  to  notice  that  in  a 
curve  that  has  been  clearly  a  typical  left  postural  one  a  few  months 
later  the  dorsal  spine  is  straightening  and  even  becoming  slightly 
curved  to  the  right,  while  the  twist  of  the  shoulder-girdle  has  dis- 
appeared or  become  reversed. 

The  mechanism  of  this  is  as  follows: 


Fig.  43. — Boy   with   Left    Scoliosis    Photographed   from    Overhead,   Showing   the 

Carrying  Back  of  the  Shoulder-girdle  on  the  Right. 

The  front  edge  of  the  board  on  the  floor  marks  the  lateral  plane  of  the  pelvis. 

Mechanism  of  Transitional  Curves. — If  total  scoliosis  tends  to  increase,  it  must 
do  so  by  an  increase  of  the  existing  side  bend  and  of  the  existing  twist,  since  both 
are  correlated,  not  necessarily  of  both  in  exact  proportion,  but  to  some  extent 
both  factors  must  share  in  it.  The  shoulder-girdle  will,  therefore,  be  more  twisted 
as  the  lateral  curve  increases.  One,  however,  does  not  see  the  condition  clinically 
of  extreme  left  total  curve  and  extreme  right  backward  rotation  of  the  shoulder- 
girdle  except,  possibly,  in  cicatricial,  hysterical,  or  paralytic  cases.  An  adjust- 
ment apparently  takes  place  when  the  tendency  of  the  total  curve  to  increase 
passes  beyond  a  certain  point.  For  the  explanation  of  this,  one  naturally 
looks  to  the  instinctive  tendency  to  equilibrium  and  balance  spoken  of  as  an  in- 
trinsic property  of  the  upright  living  spine.  There  must  be  going  on  at  all  times 
this  effort  to  square  the  shoulder-girdle  with  the  pelvis  and  to  keep  the  head  and 
upper  spine  as  nearly  as  possible  in  the  median  line  of  the  body.  This  adjust- 
ment will  naturally  occur  where  the  spine  offers  the  least  resistance  to  it,  and  as 
individual  vertebral  columns  vary,  the  compensatory  adjustment  will  take 
various  forms. 

Assume  that  a  child  stands  and  sits  with  a  left  total  curve.     He  will,  after  a 


TRANSITIONAL    CURVES 


59 


certain  point  in  the  deformity  is  reached,  he  continually  striving  instinctively  and 
unconsciously  to  twist  the  upper  part  of  his  spine  and  his  shoulder-girdle  forward 
on  the  right  and  to  bend  the  upper  part  of  his  spine  convex  to  the  right  to  restore 
his  balance.  We  have  seen  that  the  dorsal  spine  twists  more  easily  than  it 
bends  to  the  side.  He  is,  therefore,  more  likely  to  twist  his  dorsal  spine  than  to 
bend  it  to  the  side.  He  will,  for  this  reason,  twist  the  upper  dorsal  spine  to  the 
left,  which  twist,  as  we  have  seen,  necessarily  carries  with  it  a  dorsal  lateral  curve 
convex  to  the  right. 

The  tendency  to  correct  the  twist  of  the  shoulder  and  upper  end  of  the  spine 
is  sufficient  to  explain  the  transition  of  a  left  total  curve  to  a  right  dorsal,  left 
lumbar  curve.     Such  a  double  curve  can  be  reproduced  experimentally  in  the 


Fig.  44. — -The  Upper  End  of  the  Spine 
OF  THE  Cadaver  is  Held  by  the  Hand  over 
THE  Middle  of  the  Pelvis,  while  the 
Right  Side  of  the  Pelvis  is  Raised,  and 
A  Position  Like  that  of  the  Living 
Model  is  Produced  with  a  Lateral 
Curve  Convex  to  the  Left.     (Cf.  Fig.  33.) 


Fig.  45. — Experimental  Double 
Curve  (Right  Dorsal,  Left  Lltmbar) 
Produced  in  the  Cadaver  by  Elevating 
THE  Right  Side  of  the  Pelvis  and 
Twisting  the  Upper  End  of  the  Spine, 
Face  to  the  Left. 


cadaver,  the  model,  and  the  child  by  inducing  a  left  total  curve  and  adding  a 
twist,  active  or  passive,  of  the  shoulder-girdle  forward  on  the  right.  A  right 
dorsal,  left  lumbar  lateral  curve  then  exists. 

Support  is  given  to  this  idea  by  the  fact  that  in  structural  right  dorsal,  left 
lumbar  curves  with  bony  rotation,  one  is  likely  to  find  in  looking  down  upon  the 
standing  patient  that  the  left  side  of  the  shoulder-girdle  is  seen  to  be  carried 
backward  in  its  relation  to  the  pelvis  and  the  right  side  forward,  which,  of  course, 
is  the  reversed  position  to  that  seen  in  the  left  total  curve.  The  same  relation 
of  the  shoulder-girdle  is  to  be  noticed  in  single  curves  to  the  left  which  are  ac- 
companied by  bony  rotation,  the  position  again  being  the  reverse  of  that  seen  in 
left  total  scoliosis. 


6o  DESCRIPTION   AND    SYMPTOMS 

The  disappearance  of  concave-sided  torsion  which  has  once  existed  in  any 
part  of-  the  spine  may  indicate  that  the  compensatory  change  has  already  begun 
and  that  the  -so-called  total  scoliosis  has  begun  on  its  transition  to  a  compound 
curve. 

We  should,  therefore,  regard  with  suspicion  any  case  of  apparent  total  scoliosis 
that  shows  any  departure  from  the  clinical  type  described  (see  page  55),  such  cases 
probably  having  entered  on  the  stage  of  transition. 


Fig.  46. — Experimental  Double  Curve  (Right  Dorsal,  Left  Lumbar)  Produced  in 
THE  Model  by  Elevating  the  Right  Side  of  the  Pelvis  and  Having  the  Model 
Actively  twist  the  Upper  Spine,  Face  to  the  Left. 

That  left  total  curves  most  frequently  change  to  right  dorsal,  left 
lumbar  compound  curves  than  to  any  other  form  is  shown  by  the 
figures  of  Hess  and  by  a  statement  of  Schulthess.^  But  we  cannot 
expect  the  same  final  curve  always  to  result  from  the  same  initial 
curve.  Various  forms  of  curves  may  occur  from  the  same  simple 
curve.     For  example,  the  dorsal  region  may  not  react  as  described, 

^Liining  and  Schulthess:  "  Orth.  Chir.,"  1901,  page  248. 


STRUCTURAL    SCOLIOSIS  6 1 

and  the  dorsal  and  lumbar  region  may  yield,  as  a  whole,  to  the  left, 
later  showing  bony  rotation  on  the  left  side.  The  spine  has  yielded 
backward  and  to  the  left  as  a  whole,  and  other  types  of  compound 
curves  may  obviously  result  from  the  same  initial  curve. 

In  his  investigations  concerning  the  persistence  of  total  scoliosis 
Hess  records  the  observations  of  86  cases  between  the  ages  of  five 
and  twenty-one  years  during  periods  varying  from  two  weeks  to 
eight  years  and  a  half.  Of  these  86  cases,  6o  persisted  as  total  sco- 
lioses, and  the  remaining  26  underwent  various  changes,  as  shown  by 
the  list  given  below.  ,  ♦ 

{a)  Left  total  scoliosis  in — 

7  cases  changed  to  right  dorsal,  left  dorsolumbar  scoliosis. 

4  cases  changed  to  left  lumbar  curves,  with  two  right  dorsal. 

3  cases  changed  to  left  dorsal  curves. 

2  cases  changed  to  left  dorsal,  right  dorsolumbar  curves. 

2  cases  changed  to  right  dorsal  curves. 

I  case  changed  to  left  dorsal,  right  dorsolumbar. 

I  case  changed  to  slight  left  cervicodorsal  curve. 

I  case  showed  slight  compensating  curves. 


{b)  Right  total  scoliosis  in — ■ 

I  case  became  right  dorsal,  left  dorsolumbar. 

I  case  became  left  dorsal,  right  dorsolumbar. 

I  case  becsme  left  dorsal. 

I  case  became  right  dorsal. 

I  case  became  left  dorsal,  right  lumbar. 


5  cases. 


STRUCTURAL  SCOLIOSIS  (ORGANIC,  HABITUAL  OR 
TRUE  SCOLIOSIS) 

This  term  is  applied  to  those  cases  in  which  there  is  reason  to 
believe  that  a  structural  change  has  occurred  in  the  vertebrae,  which 
is  discussed  in  the  chapter  on  Pathology. 

Structural  curves  are  simple  or  compound — simple,  when  the  de- 
viation is  accompanied  by  no  compensating  curves,  e.g.,  left  lumbar 
scoliosis.  The  scoliosis  is  compound  when  more  than  one  curve  is 
present,  e.g.,  right  dorsal,  left  lumbar  scoliosis.  The  simple  curves 
have  sometimes  been  spoken  of  as  C  curves  and  the  double  as 
S  curves.  Triple  curves  at  times  exist.  When  compound  curves 
are  present,  they  alternate  to  the  right  and  left,  two  left  curves,  e.g., 
not  separated  by  a  right  curve,  never  being  seen. 


62 


DESCRIPTION   AND    SYMPTOMS 


No  attempt  has  been  made  to  discriminate  between  the  words 
"torsion"  and  "rotation,"  and  they  have  been  used  interchangeably 
in  the  text. '    The  German  writers  distinguish  between  the  two  terms 

in  a  highly  technical  way,  a 
distinction  which  it  does  not 
seem  desirable  to  transfer  to 
English. 

VARIETIES  OF  STRUCTURAL 

SCOLIOSIS  (LUMBAR 

CURVES) 

Lumbar  scoliosis  exists  as 
a  simple  curve,  but  more  often 
is  only  one  compone"ht  of  a 
compound  curve,  the  dorsal 
curve  being,  of  course,  in  the 
opposite  direction.  In  the 
Schulthess  figures  the  simple 
lumbar  curve  formed  11.7  per 
cent,  of  all  cases  treated,  and 
right  and  left  curves  were  of 
practically  the  same  fre- 
quency. It  occurs  later  than 
the  total  scoliosis,  as  shown 
by  the  ages  of  the  patients 
observed.  It  occurs  more  fre- 
quently in  females  than  in 
males  (Scholder:  13.8  per 
cent,  boys,  27.7  per  cent, 
girls.  Schulthess:  6.3  per 
cent,  males,  12.7  per  cent, 
females).  The  greatest  deviation  from  the  straight  line  is  most 
often  found  at  about  the  second  lumbar  vertebra,  and  as  the  lum- 
bar region  is  short,  the  curve  must  be  in  general  a  sharp  one. 

The  trunk  is  displaced  to  the  side  of  the  convexity  of  the  curve  and 
the  line  of  the  waist  flattened  on  that  side,  while  the  waist  on  the  con- 
cave side  of  the  curve  is  sunken  in,  and  folds  may  form  in  the  skin  of 
the  flank  on  this  side.  This  is  expressed  by  an  apparent  prominence 
and  greater  size  of  the  hip  on  the  concave  side,  and  it  is  popularly 
said  that  one  hip  has  "grown  out"  or  one  hip  is  "higher"  than  the 
other,  meaning  in  anatomical  terms  that  the  crest  of  one  ilium  is 


Fig.  47. — Left  Limbar  Scoliosis  not  Return- 
ing TO  THE  Median  Line. 
The   lines   indicate   the    median   plane    and   the 
flexibility  to  each  side. 


DORSAL   CURVES 


63 


more  prominent  than  the  other.  This  inequality  of  the  hips  and 
waist-line  is  the  most  striking  feature  of  lumbar  curves,  and  unless 
corrected,  forms  an  unsightly  deformity  in  women  with  prominent 
hips,  and  makes  it  necessary  to  make  the  skirt  longer  on  one  side  than 
on  the  other.  The  relative  height  of  the  shoulders  is  not  noticeably 
affected  by  lumbar  curves. 

As  the  patient  stands,  a  fullness  of  the  back  is  noticed  in  marked 
cases  on  the  convex  side  of  the  curve  caused  by  the  rotation  of  the 
vertebras,  which  carry  the  heavy  transverse  processes  around  and 
make  prominent  the  overlying  structures.     In  the  position  of  ex- 


FiG.  48. — Left  Lumbar  Curve  with  Slight 
Right  Dorsal  Curve. 


Fig.  49. — Left  Dorsal  Scoliosis. 


treme  forward  bending  the  side  of  the  back  which  is  on  the  convexity 
of  the  lateral  curve  is  prominent  upward,  but  lumbar  rotation  is 
always  less  prominent  than  dorsal,  and  to  the  untrained  eye  even  in 
the  severer  cases  seems  slight  (Fig.  56).  In  side  bending,  mobility  is 
greater  coward  the  side  which  makes  the  curve  worse  than  to  the  side 
which  improves  it  (Fig.  61). 

DORSAL  CURVES 

A  single  dorsal  curve  is  more  frequent  than  the  single  lumbar  type, 
but  is  much  less  frequent  than  dorsal  curves  in  combination  with  other 


64 


DESCRIPTION    AND    SYMPTOMS 


forms^  that  is  to  say,  dorsal  curves  are  more  often  than  not  accom- 
panied by  reverse  or  compensating  curves  above  or  below.  In  the 
Schulthess 'figures  there  were  19  per  cent,  of  single  dorsal  curves  and 
30  per  cent,  where  dorsal  curves  existed  with  others.  The  curves 
are  as  frequently  to  the  right  as  to  the  left  when  they  exist  alone. 
The  point  of  greatest  curve  is  from  the  sixth  to  the  eighth  dorsal  ver- 
tebra in  the  majority  of  cases. 

In  a  marked  right  dorsal  curve,  as  seen  from  behind,  the  thorax 
is  displaced  to  the  right,  and  the  right  arm  hangs  farther  from  the 

side  than  the  left;  the  right 
shoulder  is  raised  and  the 
waist-line  on  the  right  is  less 
concave  and  much  flattened 
in  the  severer  cases,  the  ribs 
coming  close  to  the  crest  of 
the  ilium  and  obliterating  the 
natural  waist  indentation. 
The  rotation  is  made  evident 
by  a  prominence,  in  the  back, 
of  the  right  side  of  the  thorax, 
which  may  be  seen  as  the  pa- 
tient stands  erect  (Fig.  50). 
Unlike  the  rotation  in  lumbar 
cases,  the  rotation  element  in 
dorsal  cases  is  a  very  marked 
feature  of  the  deformity,  and 
a  sharp  prominence  extends 
down  the  right  side  of  the 
thorax,  composed  of  the  angles 
of  the  ribs,  which  pushes  the 
scapula  backward  and  to  the  right.  The  left  side  of  the  thorax  as 
seen  from  behind  is  flat  or  concave,  the  left  scapula  sunken  and  ro- 
tated with  the  glenoid  cavity  downward  and  the  inferior  angle  in- 
ward. A  fold  in  the  skin  frequently  runs  inward  and  upward  from 
the  waist-line.  When  the  patient  bends  forward  until  the  trunk 
is  horizontal,  the  rotated  ribs  are  very  prominent  upward  on  the 
right,  and  a  long  arch  of  rib  angles  is  seen  which  is  much  more 
marked  than  in  the  standing  position.  On  the  left  side  the  ribs  are 
sunken  and  fall  away,  making  a  fiat  and  even  depressed  surface  to 
contrast  with  the  striking  prominence  of  the  right  side. 

In  a  right  dorsal  curve  the  right  shoulder  will  inevitably  be  higher 


Fig.  50.- 


-Advanced  Right   Dorsal  Scoliosis 

IN  AN  Adult. 


DORSOLUMBAR   CURVES 


65 


than  the  other  unless  a  left  compensating  cervicodorsal  curve  exists 
above  it.  The  absence  of  a  high  shoulder  on  the  convex  side  there- 
fore should  always  lead  to  an  examination  for  a  compensating 
curve  above. 

As  seen  from  the  front,  the  deformity  is  even  more  evident,  the 
thorax  is  displaced  to  the  right,  the  right  shoulder  is  higher  than  the 
left,  and  the  left  side  of  the  thorax  more  prominent  in  front  than 
the  right.  In  severe  cases  the  lower 
end  of  the  sternum  is  generally  dis- 
placed toward  the  convexity  of  the 
curve — in  this  case  to  the  right.  The 
contour  of  the  chest  is  changed,  and 
the  longest  thoracic  diameter  is  the 
oblique  antero-posterior  line  from  the 
point  rotated  backward  on  the  right 
to  the  point  rotated  forward  on  the 
left — in  this  case  from  the  right  scap- 
ula to  the  left  nipple.  This  descrip- 
tion is,  of  course,  to  be  reversed  for 
left  dorsal  curves. 

The  dorsal  physiological  curve  is 
most  often  increased,  making  the 
rounded  and  distorted  back  spoken  of 
as  kyphoscoliosis  (Fig.  51).  It  may, 
however,  be  flattened,  and  even 
slightly  concave  forward  in  the  dorsal 
region.  Loss  of  height  and  shortening 
of  the  trunk  are  evident  in  the  severer 
cases. 

The  aspect  is  wholly  different  from 
that  seen  in  lumbar  cases,  where,  as 
has  been  said,  the  chief  noticeable  dis- 
tortion is  in  the  hips  and  waist-line;  in  dorsal  cases  the  distortion  is 
most  noticeable  in  the  thorax  and  shoulders. 


Fig.  51. — Kyphoscoliosis. 


DORSOLUMBAR  CURVES 


Dorsolumbar  scoliosis  is  a  form  seen  as  a  simple  curve  with  con- 
siderable frequency  (20  per  cent.),  being,  therefore,  much  more  com- 
mon than  simple  lumbar,  but  about  as  frequent  as  simple  dorsal 
scoliosis.     It  naturally  partakes  of  the  character  of  the  two  forms 
5 


66 


DESCRIPTION   AND    SYMPTOMS 


just  described  and  affects  nine  females  to  one  male.  The  seat  of 
greatest  curve  is  generally  at  the  dorsolumbar  junction.  It  is  four 
times  as  frequently  convex  to  the  left  as  to  the  right.  The  trunk  and 
lower  thorax  are  displaced  toward  the  side  of  the  convexity  of  the 
curve  and  overhanging  the  pelvis,  and  the  waist-line  on  that  side  is 
flattened  or  obliterated,  while  on  the  concave  side  the  outline  cuts  in 

sharply  above  the  pelvis,  fre- 
quently forming  folds  in  the 
skin.  The  attitude  is  more 
like  that  of  an  exaggerated 
total  scoliosis  than  like  either 
the  dorsal  or  lumbar  form.  It 
is  not  so  prone  to  be  associ- 
ated with  compensatory 
curves  as  are  the  other  forms. 

CERVICODORSAL  CURVES 

Cervicodorsal  scoliosis  is  a 
comparatively  rare  form  of  the 
deformity,  occurring  in  only 
3.6  per  cent,  of  all  cases.  It 
is  convex  to  the  left  more 
often  than  to  the  right  in  the 
relation  of  3  to  2,  and  the 
greatest  curve  is  most  fre- 
quently located  at  the  third  or 
fourth  dorsal  vertebra.  The 
head  is  carried  forward  and 
tipped  to  the  concave  side  of 
the  curve.  The  neck  is  obvi- 
ously shortened,  and  the  outline  from  the  base  of  the  skull  to  the 
shoulder  is  fuller  and  less  crescentic  in  outline  on  the  convex  side 
of  the  curve  than  on  the  other.  The  shoulder  on  the  convex  side 
of  the  curve  is  raised  and  the  other  lowered,  and  the  scapula  of  the 
raised  side  is  conspicuously  higher.  The  arm  of  the  convex  side 
hangs  farther  from  the  side  than  the  other.  The  rotation  appear- 
ances are  marked,  and  the  sharp  angles  of  the  upper  ribs  are  promi- 
nent in  the  lower  part  of  the  curve,  while  above  the  rotation  is  less 
evident  because  there  are  only  the  transverse  processes  of  the 
cervical  vertebrae  to  make  a  projection.  The  trunk  is  displaced  to 
the  side  of  the  convexity  of  the  lateral  curve. 


Fig.  52. — Left  Dorsolumbar  Scoliosis. 


COMPOUND    STRUCTURAL   CURVES 


67 


COMPOUND  STRUCTURAL  CURVES 

The  pictures  of  compound  curves  cannot,  of  course,  be  as  simple 
or  uniform  as  those  of  the  simple  types.  A  right  dorsal  left  lumbar 
curve,  for  example,  will  present  a  combination  of  the  appearances 
described  in  both  dorsal  and  lumbar  curves;  a  right  cervicodorsal  left 
dorsolumbar,  the  sum  of  the  pictures  of  the  two  factors.     If.  the  dorsal 


Fig.  S3- — Cervicodorsal  Curve  due 
TO  Defective  Ribs  and  Malforma- 
tion   OF  VERTEBR/E. 


Fig.  54. — Right  Dorsal  Left  Lumbar 
Scoliosis. 


element  predominates,  the  appearances  will  be  more  dorsal  than  lum- 
bar, as  is  usually  the  case,  and  every  grade  of  variation  is  to  be  seen, 
the  predominant  curve  setting  its  stamp  on  the  clinical  appearance. 
The  right  dorsal  left  lumbar  curve  is  the  one  most  frequently  seen. 
Dorsal  scoliosis  with  compensating  curves  formed  30  per  cent,  of  all 
cases  in  the  Schulthess  tables,  and  of  these  the  dorsal  curve  was  to  the 
right  in  80  per  cent,  of  the  cases.     The  greatest  point  of  curve  in  these 


68 


DESCRIPTION   AND    SYMPTOMS 


was  from  the  sixth  to  the  eighth  dorsal  vertebra,  and  the  most  fre- 
quent reverse  curve  associated  was  in  the  lumbar  region.  It  is  a  type 
of  curve  most  frequently  seen  in  older  children,  the  bulk  of  the  cases 
being  from  ten  to  sixteen  years  old,  but  it  may  be  seen  in  very  young 
children.  The  increased  susceptibility  to  compound  curves  with  in- 
creasing years  is  shown  by  Scholder's  statistics  of  school  children: 


8  years  old o 

9  years  old i 

10  years  old , i 

1 1  years  old 2 

1 2  years  old 2 

13  years  old 3 

14  years  old 3 


4  per  cent. 

1  per  cent. 

2  per  cent. 
4  per  cent. 
I  per  cent. 

3  per  cent. 
3  per  cent. 


Women  are  more  frequently  affected  than  men,  the  proportion 
being  7  to  i. 

Fig.    55- — Dorsal  Rotation  Shown  by  Fig.    56. — Lumbar  Rotation  Shown  by 

Prominence   of   Right   Side  in  Bending        Prominence   of   Left    Side    in   Bending' 


The  appearances  shown  in  the  illustration  (Fig.  54)  will  serve  to 
demonstrate  how  the  appearances  of  two  types  of  simple  scoliosis  are 
brought  together  in  the  same  patient.  In  a  right  dorsal  left  lumbar 
curve,  the  appearances  of  the  thorax  are  those  described  for  a  simple 
dorsal  curve,  but  the  overhang  of  the  thorax  is  modified  by  the  dis- 
placement of  the  lower  trunk  in  the  opposite  direction  incident  to  the 
left  lumbar  curve.  The  resultant  position  may  be,  as  in  the  simple 
curves,  either  accompanied  by  an  increase  or  diminution  of  the 
physiological  curves. 

That  scoliosis  may  change  from  one  clinical  picture  to  another  in 


COMPOUND    STRUCTURAL   CURVES 


69 


the  same  patient  in  the  course  of  years  is  well  established.  Not  only 
does  the  total  curve  frequently  change  to  a  compound  type  as  men- 
tioned, but  the  structural  curves  change  the  body  outline  most  fre- 


PiQ_  57. — Severe  Dorsal  Rotation  on  Right  Side  in  Forward  Bending. 


Fig.  58. — Schulthess'  Tracing  of  a 
Girl  Six  Years  Old. — (Schulthess.) 


Fig. 


59. — Tracing  of  the  Same  Case  Eight 
Ye.\rs  L.\ter. —  {Schzilthess.) 


quently  by  the  addition  of  compensatory  curves,  e.g.,  the  illustration 
shows  the  change  of  a  left  dorsal  right  lumbar  curve  to  a  curve  of  the 
same  type  causing,  however,  a  different  distortion.  In  general,  how- 
ever, the  later  distortion  is  an  exaggeration  of  the  earlier. 


70  DESCRIPTION   AND    SYMPTOMS 

The  relative  frequency  of  the  common  types  as  tabulated  in  1137 
cases  coming  for  treatment  by  Schulthess  was  as  follows: 

Total  scoliosis iS-39  per  cent. 

Lumbar 11.  7     per  cent. 

Dorsal 19.0     per  cent. 

Dorsolumbar 20.0     per  cent. 

Cervicodorsal 3.6     per  cent. 

Compound 30 .  o     per  cent. 


CHAPTER  VI 
EXAMINATION  AND  RECORD  OF  SCOLIOSIS 


In  undertaking  the  examination  of  a  case  of  scoliosis  it  is  important 
to  obtain  a  fairly  complete  history  of  the  child's  early  life,  as  throwing 
light  on  the  cause  of  the  deformity,  and  secondly,  as  giving  informa- 
tion as  to  the  child's  condition  at  the  time  of  beginning  treatment,  as 
indicating  the  probable  resistance  to  fatigue,  the  existence  of  factors 
likely  to  complicate  treatment,  etc. ;  and,  also,  it  is  important  to  ob- 
tain as  accurate  a  record  as  possible  of  the  curve  at  the  beginning 
of  treatment  and  at  subsequent  stages.  These  two  matters  will  be 
dealt  with  in  the  order  named. 

History.  Family  History, — The  occurrence  of  scoliosis  in  other 
members  of  the  family  is  of  interest  as  posiibly  indicating  a  heredi- 
tary origin.  A  tuberculous  family  history  would  make  one  particu- 
larly careful  about  the  child's  hygiene. 

Personal  History. — The  character  of  the  labor  if  difficult  may 
point  to  the  possibiHty  of  some  injury  occurring  at  birth.  The  health 
of  the  child  as  a  baby,  whether  it  was  bottle  fed  or  nursed,  and  the 
date  of  the  first  teeth  are  important  in  their  bearing  on  rickets,  as  are 
the  existence  of  bowlegs  or  other  signs  indicating  rickets.  The  his- 
tory of  acute  illnesses  in  childhood  are  significant  in  showing  whether 
the  child  has  been  sickly  or  not,  and  any  mysterious  feverish  attack 
may  have  been  infantile  paralysis.  The  age  at  which  the  curve  was 
noticed  and  its  subsequent  progress  are  proper  subjects  of  inquiry, 
but  the  information  obtained  is  rarely  reliable. 

It  is  important  to  note  the  child's  mental  make-up,  whether  nerv- 
ous and  apprehensive  or  easy  going  and  careless,  as  it  has  a  bearing 
on  the  formulation  of  treatment.  Evidences  of  overwork  at  home 
or  at  school  are  factors  of  importance. 

The  height  and  weight  should  be  taken,  first  to  show  whether  there 
is  a  reasonable  period  of  growth  ahead  of  the  individual  child,  and  sec- 
ond, to  show  whether  the  child  is  backward  in  growth  or  decidedly 
oversize.  Great  excess  of  height  or  weight,  or  of  both,  is  important 
because  decidedly  overgrown  children  as  a  rule  show  diminished  resist- 
ance to  physical  exercise  and  seem  particularly  liable  to  defects  of 
posture.  The  height  and  weight  should  be  taken  and  compared  to 
the  average  given  in  the  table. 

71 


72  EXAMINATION  AND    RECORD    OF    SCOLIOSIS 

AvERAOE  Heights  and  Weights. — {T.  M.  Rotch) 


Boys 

Age 

G 

rls 

Height 

Weight 

Weight 

Height 

Inches 

Pounds 

Pounds 

Inches 

19-75 

7-15 

Birth 

6-93 

19.25 

24 

75 

14-30 

5  mos. 

13-86 

23 

25 

29 

Si 

20.98 

I  year 

19.80 

29 

67 

ZZ 

82 

30-36 

2  years 

29.28 

32 

94 

37 

06 

34-98 

3  years 

33.15 

36 

31 

39 

31 

37-99 

4  years 

36.36 

38 

80 

41 

57 

41.00 

5  years 

39-57 

41 

29 

43 

75 

45-07 

6  years 

43.18 

43 

35 

45 

74 

48.97 

7  years 

47.30 

45 

52 

47 

76 

53-81 

8  years 

51-56 

47 

58   ■ 

49 

69 

59-00 

9  years 

57-00 

49 

37 

51 

68 

65.16 

10  years 

62.23 

51 

34 

53 

U 

70.04 

II  years 

68.70 

53 

42 

55 

II 

76.75 

12  years 

78.16 

55 

88 

57 

21 

84.67 

13  years 

88.46 

58 

16 

59 

88 

94-49 

14  years 

98.23 

59 

94 

The  weights  at  birth,  and  in  the  first,  second,  pnd  third  years, 
were  without  clothing.  The  ordinary  school  clothes  were  worn  in 
the  weighing  from  five  to  fourteen  years.  As  the  tables  were  made 
up  from  children  in  the  public  schools,  children  in  private  practice 
will  as  a  rule  somewhat  overrun  these  figures. 


EXAMINATION 


GENERAL  CONDITION 


In  the  examination  it  is  important  to  note  the  nutrition  and  devel- 
opment, that  is,  whether  the  child  is  fat  or  thin,  flabby  or  firm,  pale 
and  anemic  or  of  good  color  and  apparently  robust.  The  nervous 
condition  of  the  patient  may  be  estimated  by  the  presence  or  absence 
of  apprehension,  crying,  twitching,  or  tremor,  but  restlessness  in 
young  children  means  nothing.  The  condition  of  the  heart  should 
always  be  examined  because  otherwise,  harmful  exercise  might  be 
prescribed  for  a  child  with  organic  heart  disease.  The  following 
points  should  also  form  part  of  a  routine  examination. 

Condition  of  lungs  and  chest  expansion.  Comparative  length  of 
legs.     The  existence  of  flat-foot  or ''weak  ankles."     Whether  or  not 


EXAMINATION   OF   SPINE  73 

spectacles  are  worn.     General  gait  and  carriage.     Manner  of  support- 
ing the  underclothes  and  stockings,  whether  objectionah)le  or  not. 

EXAMINATION  OF  SPINE 

A  patient  with  suspected  lateral  curvature  should  always  be  ex- 
amined with  the  back  wholly  bare.  The  clothes  should  be  firmly 
pinned  or  fastened  by  a  strap  around  the  hips  at  a  level  low  enough  to 
show  the  top  of  the  cleft  between  the  buttocks  and  to  show  the  out- 
line of  the  pelvis.  In  children  the  patients  should  be  stripped  to  this 
level;  in  adolescent  and  adult  young  women  the  chest  should  be  cov- 
ered by  an  apron  hanging  over  the  front  of  the  thorax,  the  strings  of 
which  are  fastened  around  the  neck. 

The  patient  should  stand,  back  to  the  surgeon,  squarely  on  both 
feet  with  the  arms  hanging  at  the  sides.  It  is  desirable  to  allow  the 
patient  to  stand  quietly  for  a  minute  or  two  before  beginning  the 
examination  in  order  to  secure  the  fatigued  or  relaxed  position  which 
is  the  characteristic  one.  The  patient  should  not  be  handled  or 
touched  during  the  first  inspection,  as  the  contact  of  the  hand  fre- 
quently stimulates  the  muscles  and  negatives  for  the  time  being  the 
relaxed  position. 

Inspection  of  the  natural  standing  position  forms  the  first  step 
in  the  examination.     The  surgeon  notices  first: 

1,  The  body  outHne,  whether  symmetrical  or  not,  comparing  on 
both  sides  the  outline  from  the  axilla  to  the  crest  of  the  ilium, 
whether  one  is  flatter  or  more  curved  than  the  other.  The  trained 
eye  estimates  this  asymmetry  as  a  lateral  displacement  of  the  thorax 
or  trunk  with  regard  to  the  pelvis,  and  it  is  the  safest  guide.  The 
appreciation  of  symmetry  or  the  absence  of  it  is  essential  in  giving 
corrective  gymnastics,  and  the  most  useful  method  to  one  trained  is 
to  erect  an  imaginary  perpendicular  from  the  cleft  between  the 
buttocks  (anal  fold),  and  estimate  whether  it  cuts  the  trunk  in  the 
middle  or  whether  more  of  the  trunk  lies  to  the  left  or  right  of  it. 
It  is  obvious  that  if  any  part  of  the  spine  is  laterally  curved,  it  must 
carry  with  it  a  segment  of  the  body  to  the  right  or  left.  This 
displacement  will  be  accompanied  by  a  change  of  body  outline,  and 
a  difference  in  body  outline  on  the  two  sides  is  presumptive  evidence 
of  a  lateral  curve.  The  outline  of  the  body  and  displacement  of  the 
trunk  to  one  side  may  always  be  seen  more  plainly  from  the  front 
than  the  back,  as  the  outline  is  sharper.  In  children  this  method 
should  follow  the  one  described. 

2.  The  surgeon  next  notices  the  level  of  the  shoulders,  whether 


74  EXAMINATION   AND   RECORD    OF    SCOLIOSIS 

one  is  higher  than  the  other,  and  whether  this  is  a  constant  position. 
The  elevation  of  one  shoulder  is  generally  a  sign  of  lateral  curvature, 
but  may  exist  rarely  with  no  perceptible  curve. 

3.  The  position  of  the  scapulae  should  then  be  noted  and  the  two 
sides  compared.  It  is  not  of  primary  importance,  but  it  is  desirable 
to  note  their  relative  distance  from  the  spine,  whether  one  or  both  of 
the  scapulae  are  displaced  forward,  and  whether  any  rotation  of  the 
bone  has  taken  place. 

4.  The  habitual  position  of  the  head  should  be  noted,  whether 
tipped  to  one  side  or  held  constantly  rotated. 

5.  The  antero-posterior  physiological  curves  should  be  investi- 
gated and  any  increase  or  diminution  of  the  dorsal  or  lumbar  curves 
noted. 

Estimation  of  the  Spinal  Curve. — Over  the  middle  of  each  spinous 
process  a  mark  is  then  made  on  the  skin  by  a  flesh  pencil  or  by  ink 
while  the  patient  still  stands  as  described.  The  skin  must  not  be 
drawn  to  one  side  or  the  other  in  making  these  marks,  or  distortion 
may  be  caused  by  the  movements  of  the  skin  over  the  bony  points. 
This  line  of  marks  is  accepted  as  representing  the  spinal  curve,  al- 
though it  does  not  accurately  represent  the  position  of  the  bodies  of 
the  vertebrae  (see  Pathology).  If  a  curve  is  present,  the  line  of  marks 
will  be  evident  as  a  curved  instead  of  a  straight  line,  for  a  normal 
spine  shows  a  line  of  marks  forming  a  straight  line  which  lies  in  the 
median  plane  of  the  body. 

There  are  now  two  questions  to  be  answered:  (i)  Is  lateral  curva- 
ture present?     (2)  If  present,  what  sort  of  a  curve  is  it? 

The  median  plane  of  the  body  is  readily  determined  by  holding  a 
plumb-line  behind  the  patient,  the  lower  part  of  which  passes  through 
the  cleft  between  the  buttocks.  In  the  normal  spine  each  mark 
will  lie  under  this  plumb-line.  The  deviation  of  any  number  of 
spinous  processes  from  this  line  represents  a  lateral  curve.  This 
method  of  erecting  a  perpendicular  from  below  is  preferable  to  the 
method  of  dropping  a  plumb-line  from  the  top  of  the  column  (the 
Beely-Kirchoff   method). 

If  a  curve  exists,  as  shown  by  the  plumb-line,  the  second  question 
arises  as  to  what  sort  of  a  curve  it  is,  whether  functional  or  structural. 

Functional  curves  have  four  definite  attributes  which,  should  be 
looked  for  (see  p.  55),  and  in  the  absence  of  any  one  of  them  the 
diagnosis  of  a  functional  curve  cannot  be  made;  under  these  con- 
ditions the  case  is,  therefore  by  exclusion,  structural.  The  curve 
is  then  described  (p.  61). 


EXAMINATION   OF   ROTATION 


75 


Cervical  curves  must  be  roughly  estimated  by  the  eye,  for  on 
account  of  the  inaccessibility  of  the  cervical  spinous  processes  and 
the  instability  of  the  head,  they  cannot  be  definitely  measured. 

Estimation  of  Rotation  or  Twist.^ — The  surgeon,  having  thus 
recognized  any  bodily  asymmetry  and  having  identified  and  defined 
the  curve,  is  in  a  position  to  investigate  the  element  of  rotation  or 
twist  which  is  essential  in  every  case. 

The  surgeon,  standing  close 
behind  the  patient,  looks  down 
on  her  shoulder-girdle  from 
above  to  estimate  whether  it 
is  in  the  same  lateral  plane 
as  the  pelvis  or  whether  twist- 
ed forward  on  one  side  and 
back  on  the  other.  This  is  of 
use  chiefly  in  postural  cases, 
and  in  structural  cases  is  of 
less  value.  By  sighting  the 
scapulae  and  back  of  the  thorax 
on  the  buttocks  it  is  easily 
seen  whether  any  twist  of  the 
thorax  has  occurred  in  relation 
to  the  pelvis.  Evidence  of  ro- 
tation of  the  ribs  or  lumbar 
transverse  processes  backward 
on  the  convex  side  of  the  lateral 
curve,  which  accompanies 
structural  cases,  will  in  severe 
cases  be  evident  in  the  stand- 
ing position,  but  it  is  generally 
examined  for  and  estimated  in 
a  position  of  forward  flexion  of 
the  trunk,  sometimes  spoken 
of  as  Adam's  position.  The 
patient  bends  forward  until  the 

trunk  is  horizontal  with  the  arms  hanging  down  and  the  knees 
not  flexed. '  In  this  position  the  patient  remains  while  the  sur- 
geon glances  along  the  back  from  behind  or  in  front,  with  his  head 
on  a  level  with  the  spine,  and  looks  to  see  v/hether  either  side  of  the 
trunk  is  more  prominent  upward  in  the  lumbar,  dorsal,  or  cervical 
region.     Any  such  upward  prominence  represents  rotation  or  twist 


Fig.  6o.- — The  Plumb-line  in  the  Cleft 
OF  THE  Buttocks  to  Determine  the  Me- 
dian Plane  of  the  Body. 


76  EXAMINATION   AND    RECORD    OF    SCOLIOSIS 

and  is  a  most  important  matter.  If  it  occurs  on  the  concave  side  of 
the  lateral  curve  and  involves  the  curved  region,  it  will  be  slight  and 
evenly  distributed  through  the  spine  and  designates  a  functional  or 
postural  curve.  That  is,  in  a  left  total  postural  curve  the  right  side 
of  the  back  will  probably  be  more  prominent  upward  in  the  forward 
bent  position. 

>  If  it  occurs  as  a  well-defined  local  upward  prominence  occupying 
the  curved  region,  it  designates  a  structural  curve  at  that  location, 
the  curve  being  convex  to  the  side  on  which  the  prominence  occurs 
and  occupying  the  same  anatomical  area.  That  is,  a  right  dorso- 
lumbar  upward  prominence  designates  a  right  dorsolumbar  struc- 
tural curve.  This  must  be  clearly  understood,  for  at  times  a  curve 
which  is  obscure  or  confusing  in  the  upright  position  is  cleared  up  by 
a  recognition  of  its  rotation  as  seen  in  the  forward  bending  position. 
Estimation  of  Spinal  Flexibility. — The  patient  should  now  lie  on 
the  face  and  the  position  of  the  spinous  processes  be  noted.  The 
marks  on  the  skin  will  represent  the  curve  of  the  spine  in  the  erect 
position,  and  any  straightening  of  the  spine  in  recumbency  will  be 
shown  by  finding  that  the  spinous  processes  form  a  less  curved  line 
than  that  marked  on  the  skin.  In  postural  curves  the  spine  will  be- 
come straight  in  recumbency,  while  structural  curves  will  be  per- 
ceptibly straighter  than  when  the  patient  is  erect.  The  patient 
should  now  be  suspended  by  a  Sayre  head  sling,  enough  to  take  the 
weight  off  of  the  spine,  and  the  straightening  of  the  spine  noted. 
This  modification  of  the  asymmetry  of  the  trunk  by  suspension  is 
important  and  should  be  carefully  studied  as  to  whether  the  asym- 
metry is  practically  unchanged,  whether  the  overhang  of  the  thorax 
is  corrected,  and  whether  the  patient  becomes  wholly  symmetrical. 
The  position  of  the  patient  in  suspension  represents  the  maximum 
that  may  be  expected  from  treatment  in  that  individual  case  until 
further  flexibility  is  restored  by  treatment  directed  to  that  end. 
The  restoration  of  complete  or  almost  complete  symmetry  by  sus- 
pension points  to  an  early  case  and  one  amenable  to  treatment,  for 
one  of  the  early  changes  in  structural  curves  is  a  stiffening  of  the 
curved  region  of  the  spine  which  causes  the  persistence  of  the  curve 
under  suspension.  So  far  as  possible  it  should  be  noted  whether  the 
improvement  in  symmetry  is  produced  by  a  straightening  of  the 
curve  or  curves  or  whether  the  modification  in  asymmetry  is  pro- 
duced by  the  other  parts  of  the  spine.  For  example,  in  a  dorsal 
curve  is  the  relation  of  the  curved  region  changed  or  is  the  curved 


X-RAY  77 

part  simply  pulled  away  from  the  pelvis  by  a  stretching  out  of  the 
lumbar  region? 

The  patient  should  then  bend  forward  to  determine  normal  flexi- 
bility forward.  The  average  child  can  touch  the  floor  with  the  fin- 
gers while  the  knees  are  straight,  while  in  adult  life  less  flexibility 
is  obtained.. 

The  flexibility  of  an  individual  spine  is  a  matter  determined  by 
age,  habit,  and  individual  peculiarity.  To  know  in  a  general  way 
what  the  normal  flexibility  at  a  given  age  should  be,  is  important  in 
children,  but  in  adults  it  is  so  much  a  matter  of  individual  habit  that 
it  is  of  less  importance.  One  man  of  fifty,  for  example,  who  has 
taken  exercise  may  be  able  to  touch  the  floor  with  his  hands  in  for- 
ward bending,  while  another  man  of  the  same  age  of  sedentary  life 
cannot  get  his  finger-tips  within  a  foot  of  the  floor  in  the  same  posi- 
tion, yet  both  spines  are  to  be  classed  as  normal.  How  rapid  the 
change  in  flexibility  may  be  owing  to  exercise  is  shown  by  the  case  of 
a  healthy  boy  of  fifteen  who  could  not  touch  the  floor  with  his  finger- 
tips in  forward  bending.  He  injured  his  knee  and  was  obliged  to 
wear  a  ham-splint.  The  exertion  necessary  to  dress  himself  with  his 
leg  stiff  so  increased  his  forward  flexibility  that  in  ten  days  he  could 
place  the  palms  of  his  hands  on  the  floor  without  exertion  in  forward 
bending. 

The  patient  then  stands  with  the  elbows  out  and  the  hands  clasped 
behind  the  neck,  and  bends  to  one  side  and  to  the  other.  The  char- 
acteristics of  side  bending  have  been  fully  described,  and  modifica- 
tions and  restrictions  of  this  are  to  be  studied.  Patients  with  curves 
can,  as  a  rule,  bend  better  to  the  side  that  makes' the  curve  worse  than 
to  the  side  that  improves  it. 

The  examination  has  been  dealt  with  thus  at  length  because  rational 
treatment  cannot  be  undertaken  without  a  clear  formulation  of  the 
character  of  the  deformity,  and  experience  shows  that  in  the  loose 
use  of  terms  and  in  slipshod  examinations  certain  failures  to  obtain 
proper  results  from  treatment  have  their  origin. 

X-ray. — The  x-ray  is  of  use  in  showing:  (i)  the  existence  of  bony 
defects,  numerical  variation,  or  other  anomalies  of  the  spine;  (2)  the 
degree  of  distortion  of  the  individual  vertebrae;  and  (3)  the  degree 
and  character  of  the  curve.  The  results  of  x-ray  photographs  do  not 
as  a  rule  agree  with  the  clinical  appearances,  the  amount  of  curve 
in  the  x-ray  being  generally  more  than  is  indicated  by  the  marks 
over  the  spinous  processes.  The  amount  of  rotation  is  indicated  in 
the  x-ray  by  the  position  of  the  shadow  of  the  spinous  processes  in 


78 


EXAMINATION   AND    RECORD    OF    SCOLIOSIS 


relation  to  the  shadows  of  the  bodies,  normally  the  spinous  process 
appearing  in  the  middle  of  the  body.  But  the  element  of  distortion 
in  .T-rays  must  be  remembered.  A  patient  is  likely  to  be  twisted  by 
lying  on  the  back  if  rotation  is  present,  and  any  deviation  of  the 


Fig.  6i. — -Patient  with  a  Right  Dorsal  Left  Lumbar  Structural  Curve  Bending 
TO  the  Left  and  Right,  Showing  the  Comparative  Rigidity  of  the  Lumbar  Region 
to  Left  Bending  and  of  the  Dorsal  Region  to  Right  Bending. 


tube  from  the  middle  line  of  the  body  is  expressed  as  distortion  of 
the  vertebrae,  yet  x-rsLys  to-day,  taken  under  proper  conditions, 
afford  the  best  and  most  reliable  index  of  the  degree  of  the  curve  and 
progress  under  treatment,  for  reasons  explained  on  p.  77. 


RECORD    OP    SCOLIOSIS  79 

RECORD 

An  accurate  and  simple  method  of  recording  scoliosis  would  be  of 
great  value  to  the  general  practitioner  and  to  the  specialist,  but  no 
such  method  exists  to-day,  although  many  have  been  described  and 
advocated.  The  a;-ray  taken  under  the  conditions  described  above 
is  probably  the  most  accurate  at  our  disposal.  Photography  is  an 
easy  means  of  record,  but  does  not  fairly  represent  the  position  of 
the  spine  and  simply  gives  the  body  outlines,  and  we  shall  see  that 
a  photographic  overcorrection  may  be  obtained  with  little  or  no 
change  in  the  spine,  etc.  (ref.  p.  184).  So  we  must  remember  the 
limitations  of  photography,  and  that  in  the  severer  curves  it  may 
mislead  us  wholly  as  to  progress,  but  it  constitutes  a  fair  rough 
method  for  the  recording  of  bodily  asymmetry  caused  by  scoliosis. 
In  taking  photographs  the  following  rules  must  be  observed: 

I.  The  patient  must  stand  at  ease  with  the  legs  straight  and  the 
arms  hanging  at  the  sides  in  the  relaxed  position.  2.  The  heels  of 
the  patient  must  be  on  a  line  parallel  to  the  lens,  otherwise  distortion 
is  inevitable.  3.  The  patient  must  stand  at  a  fixed  distance  from 
the  camera  in  all  cases  if  pictures  are  to  be  used  as  accurate  records. 
4.  The  light  should  be  oblique  from  behind,  preferably  diffused,  and 
not  the  direct  light  of  the  sky  if  possible,  which  gives  too  violent  con- 
trasts between  light  and  shadow.  A  light  from  overhead  throws 
the  shadow  of  the  shoulders  onto  the  back  and  obscures  the  spinal 
furrow.  A  light  directly  from  behind  gives  a  flat  white  picture  with- 
out contours.  A  light  directly  from  the  side  throws  the  shaded  part 
of  the  body  into  such  blackness  that  the  body  outline  of  that  side  is 
lost.  A  crossed  light  obliterates  contour  and  gives  a  flat  and  con- 
fusing picture.  5.  The  shadows  should  be  diminished  by  a  white 
reflector  on  the  side  of  the  patient  away  from  the  light.  By  this 
arrangement  contour  may  be  secured  in  the  picture.  6.  The  un- 
steadiness and  swaying  of  the  patient  may  be  obviated  in  a  measure 
by  placing  an  ordinary  photographer's  rest  against  the  chest. 

A  photograph  of  rotation  may  be  obtained  by  having  the  patient 
bend  forward  with  the  head  away  from  the  camera  and  focusing  on 
the  part  of  the  back  affected  by  the  rotation. 

If  it  is  desired  to  measure  and  study  the  curve  from  the  finished 
photograph,  the  method  devised  by  Fitz  may  be  used.^ 

Various   modifications   of   the  simple  photographic  method   by 

1  G.  W.  Fitz:  "Bos.  Med.  and  Surg.  Jour.,"  Nov.  16,  1905. 


8o 


EXAMINATION   AND    RECORD    OF    SCOLIOSIS 


means  of  screens,  standard  positions,  etc.,  have  been  devised,^  of 
which  that  of  Bucholz  and  Osgood  seems  simple  and  accurate,-  but  it 


Fig.  62. — Leveling  Apparatus  (Nivellier  Trapez)  for  the  Measurement  of  Rotation 
^•:  IN  THE  Forward  Bent  Position. — (Schulthess.) 


Fig.  63. — ^ScHULTHESs'  Measuring  Apparatus. 

must  be  remembered  with  regard  to  these  that  the  photographic 
method  possesses,  and  always  will  possess,  an  intrinsic  inaccuracy  as 
explained. 

1  "Festschrift  fiir  J.  Berg."     "Nordiskt  medicinskt.  Arkiv.,"  1911. 

2  "Am.  Journ.  Orth.  Surg.,"  xii,  1914,  77. 


RECORD    OF    SCOLIOSIS 


8l 


Tracing. — A  simple  and  approximately  accurate  record  may  be 
made  by  marking  the  spinous  processes  and  laying  on  the  back,  while 
the  patient  stands  erect,  a  strip  of  crinoline  gauze,  through  which  the 
spinal  marks  may  be  seen.  They  are  thus  easily  marked  on  the 
gauze,  which  may  be  kept  as  a  record.  The  error  lies  in  the  possible 
slipping  of  the  gauze  and  the  necessity  of  placing  the  hands  on  tlie 
patient. 


Fig.  64. — Tracing  of  a  Left  Dorsal  Right  Lumbar  Curve  Made  by  the  Schulthess 
Measuring  Apparatus. — {Children's  Hospital.) 

Any  one  interested  in  the  subject  may  find  a  number  of  methods 
described,  together  with  the  literature  of  the  subject,  in  the 
reference.^ 

Rotation  may  be  estimated  in  degrees  with  accuracy  in  the  forward 
bent  position  by  means  of  the  Schulthess  level  square  (Nivellier 
Trapez),  which  consists  of  two  arms  sliding  on  a  rod  to  which  they  are 
at  right  angles.     These  arms  are  placed  on  corresponding  levels  of  the 

^  "Ueber  die  Messmethoden  des  Riickens,"  Hovorka,  Wien   igo4. 
6 


82  EXAMINATION   AND    RECORD    OF    SCOLIOSIS 

back  at  equal  distances  from  the  spine,  and  the  rod  is  provided  with 
a  protractor  and  swinging  weight  to  show  the  inclination  of  the  rod 
to  the  horizontal  plane  in  degrees  (Fig.  62). 

Methods  which  would  estimate  the  rotation  while  the  patient  lies 
prone  on  the  face  are  inaccurate,  because  the  pressure  of  the  table  on 
the  prominent  side  of  the  front  of  the  thorax  tends  to  rotate  the  chest 
and  cause  distortion. 

The  Schulthess  Apparatus  for  the  Record  of  Scoliosis. — The 
Schulthess  apparatus,  which  has  been  generally  accepted  in  Europe  as 
being  the  most  accurate  means  of  record  at  our  disposal,  consists  of 
an  upright  frame  in  which  the  patient  stands,  the  pelvis  being  fixed  by 
clamps  and  the  sternum  steadied  by  an  adjustable  rod.  Behind  the 
patient  there  is  a  sliding  bridge  with  counterweights  which  move  up 
and  down  on  the  uprights.  Attached  to  this  bridge  is  a  pointer  which 
moves  forward  and  backward  and  sideways.  The  movements  of  this 
pointer  by  an  arrangement  of  weights  and  pulleys  are  recorded  upon 
two  glass  panels  parallel  to  the  sagittal  and  frontal  plane  of  the  body 
by  means  of  pencils  moving  on  paper  attached  to  the  glass  panels. 
By  tracing  from  below  upward  the  marked  lines  of  spinous  processes 
on  one  panel,  the  antero-posterior  curve  of  the  spine  is  recorded, 
while  on  the  other  the  lateral  curve  is  simultaneously  marked. 

By  a  longer  pointer  the  lateral  body  outline  is  then  traced  in  the 
frontal  plane  after  the  position  of  the  scapulae  has  been  recorded. 
The  two  pencils  in  use  are  then  thrown  out  of  action,  and  by  means 
of  a  third  pencil  working  upon  a  glass  plate  on  the  sliding  bridge 
horizontal  contours  are  recorded  at  three  levels.  By  means  of  an 
additional  sliding  bridge  working  in  front  of  the  apparatus  a  late 
modification  of  it  provides  for  anterior  as  well  as  posterior  contours, 
which  may  be  joined  to  give  a  complete  contour  of  the  body  at 
different  levels  (Fig.  63). 

The  apparatus  is  expensive  and  complicated,  and  its  successful 
use  demands  much  training. 


CHAPTER  VII 
PATHOLOGY 

The  pathological  changes  in  the  vertebral  column  to  be  described 
as  existing  in  scoliosis  consist  of  modifications  in  shape  and  structure 
of  the  bones  and  soft  parts.  In  addition  to  these  there  are  found  at 
times  congenital  anomalies  of  the  vertebrae,  changes  due  to  rickets, 
the  pathological  results  of  empyema  and  infantile  paralysis,  all  of 
which  are  to  be  regarded  as  primary  and  causative  of  the  changes  to 
be  described.  In  other  cases  no  pathological  changes  in  addition  to 
those  described  are  to  be  found.  These  matters  will  be  discussed 
more  fully  in  speaking  of  etiology. 

The  pathological  changes  occurring  in  scoliosis  may  vary  from 
moderate  asymmetry  to  extreme  distortion.  In  general,  the  spine 
is  curved  to  one  side  in  some  part  of  its  length,  or  it  is  curved  in  one 
direction  in  one  part,  and  in  the  opposite  direction  above  or  below  or 
both  above  and  below.  These  curves  are  formed  by  the  deviation 
of  the  vertebras  from  the  median  sagittal  plane  of  the  body  and.  are 
more  marked  in  the  column  of  bodies  than  in  the  column  of  arches. 
The  lateral  curve  may  be  a  general  sweep  to  one  side,  or  it  may  be 
sharp  and  in  the  severer  cases  angular.  In  the  severer  cases  it  exists 
not  alone  in  the  presacral  vertebrae,  but  may  also  involve  the  sacrum 
and  coccyx. 

In  addition  to  the  lateral  deviation,  the  curved  region  is  rotated  or 
twisted  on  a  vertical  axis,  the  bodies  of  the  vertebrae  always  turning 
toward  the  convex  side  of  the  lateral  curve.  This  rotation  is  the  me- 
chanical accompaniment  of  the  lateral  curve,  and  one  cannot  exist 
without  the  other,  although  in  some  cases  the  rotation  is  out  of  pro- 
portion to  the  lateral  deviation,  and  in  other  cases  the  lateral  curve 
predominates  over  the  rotation. 

In  connection  with  the  lateral  curve,  alteration  in  the  normal 
antero-posterior  physiological  curves  may  occur,  as  mentioned.  The 
relation  of  these  changes  to  the  lateral  curve  is  but  little  understood. 

Such  being  the  gross  pathological  changes  occurring  in  the  spine  as 
a  whole,  it  will  add  to  clearness  in  considering  this  most  complex  mat- 
ter to  take  up  individually  the  alterations  in  the  separate  elements. 

83 


84 


PATHOLOGY 


Fig.  -65. — Scoliotic  Spine  from  the   Dwight  Collection  of  Abnormal  Spines  in  the 

Warren  Museum. 
Sacralization  of  the  twenty-sixth  vertebra  on  the  right.     Thirteen  dorsal  and  six  lum- 
bar vertebrae.     Fusion  of  several  vertebras  and  of  first  three  ribs  on  the   eft.     The  changes 
in  the  vertebral  bodies  are  characteristic  of  severe  scoliosis. 


CHANGES   IN   THE   VERTEBRA 


8S 


CHANGES  IN  THE  VERTEBRA 

Vertebral  Bodies. — ^The  scoliotic  vertebrae  are  to  be  divided  into 
two  classes,  according  to  their  pathological  changes,  those  in  the  angle 
of  the  curve  being  called  wedge  vertebrae,  while  those  between  the 
apices  of  the  curves  or  between  the  apices  and  the  normal  portion  are 
called  lozenge-shaped  or  oblique  vertebrae.  Pure  forms  of  wedge- 
shaped  and  lozenge-shaped  vertebrae  are  rare,  and  both  processes 
are  common  in  the  same  vertebra. 

A  certain  amount  of  rotation  and  also  a  transverse  displacement 
of  one  vertebra  upon  another  is  normally  possible  up  to  a  certain 
degree  on  account  of  the  elasticity  of  the  intervertebral  discs  and  the 


Fig.  66.^A  "Wedge"  Vertebra. — 

{Schulthess.) 

Second  lumbar  seen  from  in  front;  left 

lumbar  curve. 


Fig.    67. — An   "Oblique"   Vertebra. — ■ 

(Schulthess.) 

Fourth  lumbar  seen  from  the  front; 

from  a  left  lumbar  curve. 


play  of  the  ligaments,  but  early  in  the  affection  the  pathological  process 
is  not  satisfied  with  the  normal  excursions,  but  rotates  the  vertebra 
in  its  structure.  This  rotation  is  expressed  in  the  relation  of  the 
upper  and  under  surfaces  of  the  vertebral  body  and  in  a  twist  be- 
tween the  body  and  arch. 

Wedge  VertebrcB. — The  vertebrae  at  the  apex  of  the  lateral  curve 
and  just  above  and  below  it,  from  one  to  five  in  number,  are  called 
the  wedge  or  apex  vertebrae  (Keil-  or  Scheitelwirbel),  and  are  com- 
pressed on  one  side  and  consequently  wedge-shaped.  The  obliquity 
may  affect  chiefly  the  upper  surface  when  the  vertebrae  are  below  the 
apex  of  the  curve,  and  the  lower  surface  chiefly  when  they  are  above 
it,  but  it  may  affect  both  upper  and  lower  surfaces  nearly  equally,  as 
in  the  vertebra  at  the  point  of  the  curve,  and  some  modification  of 
both  surfaces  is  generally  to  be  noted.  The  thinnest  part  of  a  wedge 
vertebra  is  found  on  the  side  of  the  concavity  of  the  lateral  curve  and 


86  PATHOLOGY 

generally  toward  the  posterior  aspect  of  the  body.  The  side  of  the 
body  toward  the  concavity  is  broadened  and  lipped  in  severe  cases, 
and  synostosis  between  two  vertebral  bodies  may  occur  in  this  loca- 
tion. The- apex  vertebrae  are  rotated,  as  a  whole,  toward  the  con- 
vexity of  the  lateral  curve. 

Lozenge-shaped  Vertebrce  (torsion  vertebrae,  oblique  vertebras, 
Interferenz-  or  Schragwirbel). — The  vertebrae  between  the  apex  ver- 
tebras of  the  two  curves  or  between  the  apex  vertebrae  and  normal 
vertebra  are  deformed  in  a  somewhat  different  manner.  The  upper 
surface  of  the  vertebra  is  displaced  on  the  lower  in  such  a  way  that 
the  outline  of  the  vertebra  is  lozenge-shaped,  the  longest  diagonal 
axis  being  toward  the  apex  of  the  lateral  curve,  the  top  of  the  verte- 
bra being  moved  sideways  on  the  bottom.  Such  vertebras  may 
show  oblique  ridges  on  the  front  of  the  body.  The  upper  part  of  the 
body,  moreover,  twists  on  the  bottom  part,  below  a  right  dorsal 
curve,  the  upper  part  of  the  vertebra  twisting  in  the  same  direction  as 
would  the  hands  of  a  watch,  while  above  the  apex  of  the  curve  the 
twist  occurs  in  the  opposite  direction.  This  is  called  longitudinal 
torsion. 

The  vertebral  foramen  in  the  dorsal  region,  instead  of  being  round 
as  in  the  normal,  in  severe  scoliosis  becomes  pointed  at  the  side 
toward  the  concavity.  In  the  lumbar  region  the  normal  triangular 
shape  is  distorted  by  being  irregularly  blunted  at  the  angle  on  the 
side  of  the  concavity. 

Arches  of  the  Vertebrae. — Pedicles. — In  the  wedge  vertebra  the 
original  elevation  of  the  pedicles  may  be  retained.  As  a  rule,  they 
are  lowered  on  the  concave  side  of  the  curve  and  tend  to  be  more 
oblique  on  the  convex  side,  but  in  the  vertebra  at  the  point  of  the 
curve  they  may  be  alike  on  the  two  sides.  The  pedicle  on  the  convex 
side  is  directed  straight  backward  and  the  other  backward  and 
outward.  In  the  dorsal  vertebrae  the  pedicle  of  the  concave  side  may 
be  narrowed,  but  in  the  lumbar  region  it  is  more  generally  broadened 
and  the  transverse  process  becomes  smaller.  In  the  lozenge  vertebrae 
below  the  apex  the  pedicles  are  likely  to  be  depressed  and  above  it 
elevated,  according  to  the  intensity  of  the  curve.  In  severe  scoliosis 
the  shortening  of  the  trunk  is  so  great  that  the  vertebras  are  pressed 
together,  and,  as  the  bodies  offer  less  resistance  to  compression  than 
the  arches,  the  displacement  of  the  pedicles  on  the  bodies  is  brought 
about. 

Articular  Processes. — The  articular  processes  being  connected  with 
the  pedicles  share  in  any  change  that  they  undergo.     Owing  to  the  fact 


CHANGES   IN  THE  VERTEBRA  87 

that  the  joint  planes  are  so  different  in  the  dorsal  and  in  the  lumbar 
regions  the  pathological  appearances  differ  widely  in  the  articular 
facets  of  the  dorsal  and  lumbar  vertebrae.  The  crowding  together  of 
the  articular  processes  on  the  concavity  of  the  lateral  curve  results  in 
an  enlargement,  deepening,  and  broadening  of  the  joint  surfaces, 
while  on  the  convex  side  the  facets  are  smaller  and  higher.  In  the 
lumbar  region  the  superior  articular  facets  on  the  concave  side  are 
hollowed  out,  while  the  inferior  ones  are  correspondingly  prominent 
and  rounded,  and  the  cartilage  is  thickened  on  the  concave  side. 
The  involvernent  of  these  joints  is  a  matter  of  some  practical  impor- 
tance, and  the  changes  suggest  an  adaptation  to  greater  demands  on 
the  joints  on  the  concave  side  of  the  column.  Synostosis  may  occur 
in  these  joints,  and  the  ligaments  may  share  in  the  ossification. 

Transverse  Processes. — The  transverse  processes  tend  to  remain 
more  horizontal  than  the  body  of  the  affected  vertebra,  and  as  the 
vertebra  becomes  inclined  to  the  horizontal  plane  by  the  changes 
described,  the  transverse  processes  strive  to  remain  as  nearly  hori- 
zontal as  possible.  Not  infrequently  the  transverse  processes  are 
shorter  and  thicker  than  normal  on  the  convex  side  above  and  below 
the  apex  of  the  curve. 

Spinous  Processes. — The  spinous  processes  are  deflected  toward 
the  convexity  of  the  lateral  curve  in  the  dorsal  region.  This,  it 
seems,  may  be  explained  as  being  the  natural  position  when  the  spine 
is  laterally  curved  and  is  retained  in  a  scoliotic  position  under  the 
effect  of  muscular  pull,  while  the  bodies  of  the  vertebrae,  being 
influenced  largely  by  weight  bearing,  an  individual  plasticity  of  bone, 
and  certain  unformulated  conditions,  are  forced,  as  has  been  said, 
from  the  concavity  to  the  convexity  of  the  curve. 

In  the  lumbar  region  in  severe  cases  the  spinous  processes  are 
diverted  toward  the  concavity.  This  deviation,  it  would  seem,  is 
the  result  of  a  moving  to  the  side  of  the  root  of  the  spinous  process 
from  extreme  rotation,  as  the  tips  of  the  processes  show  the  endeavor 
to  conform  to  the  usual  position  by  being  in  some  degree  approxi- 
mated to  the  convexity  of  the  curve.  In  the  dorsal  region  the  spin- 
ous processes  are  also  displaced  downward,  and  the  direction  of  each 
spinous  process  is  therefore  influenced  by  its  contact  with  the  one 
below  it. 

The  angle  between  the  lower  border  of  the  spinous  process  in  this 
region  and  the  arch  becomes  on  the  convix  side  smaller  and  on  the 
concave  side  larger  than  normal,  and  the  appearance  of  displacement 
to  the  convex  side  is  thus  increased.     If  the  arch  is  displaced  hori- 


PATHOLOGY 


zontally  upon  the  vertebral  body,  as  described  above,  by  the  lowering 
of  one  pedicle  and  the  elevation  of  the  other  the  spinous  process  un- 
dergoes a  rotation  around  its  own  longitudinal  axis.  The  irregularity 
of  these  appearances  may  be  explained  by  the  pull  of  the  muscles,  a 
matter  which  is  at  present  imperfectly  formulated. 

Joints  between  Vertebrae  and  Ribs. — ^These,  of  course,  are  of  two 
kinds:  first,  the  joints  between  the  heads  of  the  ribs  and  the  sides 
of  the  vertebrae;  second,  the  joints  between  the  tubercles  of  the 
ribs  and  the  transverse  processes.  These  are  both  similarly  affected 
in  severe  scoliosis,  being  deepened  on  the  side  of  the  convexity  and 
faintly  indicated  on  the  side  of  the  concavity,  especially  above  the 


Fig.  68. — Distorted  Antero-posterior  Plane  of  a  Scoliotic  Vertebra. — (Riedinger). 

apex  of  the  curve.  The  articular  facets  on  the  side  of  the  vertebral 
body  are  moved  forward  on  the  concave  side  and  backward  on  the 
convex  side. 

INTERVERTEBRAL  DISCS 

These  show  the  earliest  changes,  and  at  the  points  of  greatest 
curve  are  compressed  and  project  beyond  the  edges  of  the  vertebral 
bodies  as  if  the  bodies  had  grown  into  them.  On  the  convex  side 
they  are  thicker  than  on  the  other. 

LIGAMENTS 

On  the  side  of  the  concavity  the  anterior  common  ligament  is  dense 
and  thick,  while  on  the  convex  side  of  the  curve  it  is  thinned  and 
shows  no  definite  lateral  border.     In  the  lozenge-shaped  vertebrae  the 


MUSCLES  89 

fibers  run  obliquely  in  a  direction  corresponding  to  the  ridges  on  the 
anterior  surface  of  the  vertebral  bodies.  The  posterior  common  liga- 
ment near  the  apex  is  found  more  to  the  convex  side  than  normal 
because  its  insertions  into  the  intervertebral  discs  do  not  share  in  the 
broadening  out  of  the  concave  side  of  the  vertebral  bodies,  and  the 
vertebra  thus  grows  to  the  concave  side,  while  the  ligament  remains 
more  nearly  in  the  middle.  The  ligaments  connecting  the  heads 
of  the  ribs  and  the  spine  are  long  and  atrophied  on  the  convex  side 
and  short  and  tense  on  the  concave  side. 

MUSCLES 

Where  muscles  are  thrown  out  of  use  they  atrophy  and  may  undergo 
fatty  or  fibrous  degeneration.  When  increased  demands  are  made 
upon  them  they  hypertrophy.  When  under  changed  conditions  they 
pass  over  a  surface  of  bone  they  may  become  tendinous  where  the 
contact  occurs.  Nutritive  or  adaptive  shortening  occurs  when  the 
ends  of  muscles  are  approximated.  All  these  changes  are  to  be  found 
in  cases  of  severe  scoliosis,  but  the  muscular  changes  in  slight  scoliosis 
have  not  been  formulated. 

The  change  which  muscles  undergo  in  lateral  curvature  is  first  of 
all  a  change  of  direction  of  pull  caused  by  the  displacement  of  the 
thorax  in  relation  to  the  pelvis  toward  the  right  or  left.  For  example, 
if  the  trunk  is  displaced  toward  the  left,  the  muscles  taking  origin 
from  the  crest  of  the  ilium  are  directed  toward  the  left  at  their  inser- 
tion in  the  spine.  Under  normal  conditions  the  contractility  of  the 
muscles  would  be  sufficient  to  bring  them  back  to  their  normal  posi- 
tions, but  in  a  strong  lateral  inclination  of  the  lumbar  segment  above 
the  sacrum  the  psoas  muscle,  for  example,  acquires  a  broad  insertion 
and  becomes  fan-shaped,  thereby  assuming  a  different  function. 
Under  normal  conditions  the  insertion  of  this  muscle  is  more  linear 
and  placed  at  an  acute  angle  to  its  direction  of  pull. 

Following  the  impairment  of  function  of  the  muscles  on  the  con- 
cave side  of  the  lateral  curve,  in  severe  cases  fatty  degeneration  is 
observed.  On  the  convex  side  the  muscles  are  wasted  and  thin,  and 
sometimes,  in  exceptional  cases,  fatty  degeneration  is  found  here  also. 
On  the  convex  side  more  often  a  fibrous  degeneration  is  found;  that 
is,  atrophy  of  the  muscular  tissue  and  the  formation  of  larger  tendons. 
In  addition  to  all  of  this  the  stiffness  of  the  column,  which  sets  in 
fairly  early  in  moderate  and  severe  grades  of  scoliosis,  tends  to  cause 
atrophy  of  the  muscles  of  the  back  in  general,  the  atrophy  of  disuse. 


90 


PATHOLOGY 


The  diaphragm  assumes  an  oblique  position  and  is  lower  on  the 
side  of  the  convexity  of  the  dorsal  curve.  If  the  apex  of  the  dorsal 
curve  is  situated  high  up  and  associated  with  kyphosis,  the  top  of  the 
diaphragm  may  be  much  elevated — even  as  high  as  the  level  of  the 
third  rib. 

THORAX 

In  lumbar  scoliosis  the  changes  in  the  thorax  are  slight,  but  some 
rotation  of  the  structure  as  a  whole  is  noted  in  relation  to  the  frontal 
plane  of  the  pelvis. 


Fig.  69. — R.\DioGRAM  of  Left   Scoliosis,   Resulting  from   Empyem.\  of  the  Right 
Side  with  Resection  of  the  Ribs. 

In  dorsal  scoliosis  the  thorax  is  not  only  displaced  as  a  whole 
toward  the  convexity  of  the  curve,  but  its  structure  is  distorted. 
The  thorax  as  a  whole  tends  to  retain  its  normal  position  with  regard 
to  the  frontal  plane  of  the  body  more  closely  than  does  the  spine, 
which,  as  it  were,  rotates  in  the  thorax.     It  thus  undergoes  a  twist  in 


THORAX 


91 


the  opposite  direction  from  that  of  the  spine.  This  results  in  a 
change  in  its  horizontal  diagonal  diameters,  by  which  the  one  from 
the  side  of  the  convexity  behind,  to  the  concavity  in  front  is  length- 
ened, and  the  corresponding  one  on  the  other  side  is  shortened.  For 
example,  in  right  dorsal  scoliosis  the  thorax  is  displaced  to  the  right 
and  becomes  prominent  on  the  right  side  behind  and  the  left  side  in 
front,  and  the  diagonal  diameter  from  the  right  side  behind  to  the 
left  side  in  front  is  lengthened.  As  a  result  of  this  the  internal  sur- 
faces of  the  shafts  of  the  right  ribs  are  brought  nearer  to  the  front  of 
the  vertebral  bodies,  and  the  right  side  of  the  thorax  is  seriously 
diminished  in  capacity. 


Fig.  70. — Thoracic  Ring  in  a  Right  Dorsal  Scoliosis,  seen  from  Above. — {Lorenz.) 


Ribs. — The  ribs  on  the  convex  side  of  the  lateral  curve  show  a 
backward  increase  of  their  angularity,  forming  on  the  side  of  the 
back  of  the  thorax  a  more  or  less  sharp  and  prominent  ridge,  spoken 
of  technically  as  ''the  rotation"  (Rippenbuckel).  In  compound 
curves  of  the  dorsal  region  these  phenomena  accompany  each  curve. 
From  the  angle  forward  to  the  sternum  the  ribs  of  the  convex  side 
show  a  loss  of  their  normal  curve. 

The  ribs  on  the  side  of  the  concavity  of  the  lateral  curve  show  a 
straightening  of  their  angles  and  an  increased  outward  bowing  of 
their  shafts.     The  costal  cartilages  of  the  concave  side  in  front  show 


92  PATHOLOGY 

an  increased  curvature  forward  and  form  on  the  front  of  the  chest  a 
prominence  at  the  side  of  the  sternum  (vordere  Rippenbuckel). 

The  ribs  of  the  side  of  the  convexity  are  spread  apart  and  have 
a  more  oblique  direction;  on  the  side  of  the  concavity  they  are  closer 
together  and  tend  to  a  more  horizontal  course.  These  phenomena 
are  dependent  upon  the  degree  of  inclination  of  the  part  of  the  spine 
to  which  the  ribs  are  attached. 

Stemiun. — The  sternum  as  a  rule  deviates  but  little  from  its  nor- 
mal position  and  direction  except  in  very  severe  scoliosis.  The 
variations  in  position  consist — (i)  In  a  lateral  displacement;  (2)  in 
an  obliquity  of  the  lower  end,  which  turns  either  to  the  convexity  or 
concavity  of  the  lateral  curve;  (3)  in  a  rotation  around  its  longitudi- 
nal axis,  making  one  lateral  border,  commonly  the  one  toward  the 
concavity  of  the  lateral  curve,  more  prominent.  A  detailed  study 
of  the  variations  of  the  sternum  may  be  found  in  the  reference.^ 

SHOULDER-GIRDLE 

The  marked  deformity  of  the  thorax  cannot  be  without  influence  on 
the  form  of  the  clavicles  and  scapulae.  The  scapula  undergoes,  be- 
cause of  the  deformity,  various  changes  of  position  and  eventually  of 
form.  It  always  acquires  that  position  to  which  it  is  forced  by  the 
form  of  the  thorax,  the  weight  of  the  shoulder  and  arm,  and  the  ten- 
sion of  its  muscles.  On  account  of  the  backward  prominence  of  the 
thorax,  the  scapula  is  moved  away  from  the  vertebral  column  on  the 
convex  side,  and  if  the  scoliosis  is  located  high  up  in  the  dorsal  region, 
the  scapula  moves  upward  also.  If  the  thorax  is  strongly  compressed 
from  the  side,  the  scapula  may  lie  sidewise,  so  that  its  dorsal  surface 
has  a  lateral  and  not  a  backward  direction,  or  it  may  swing  backward 
so  that  its  inferior  angle  crosses  the  line  of  spinous  processes  to  the 
other  side.  It  may  furthermore  acquire  a  strong  curve  on  itself  if 
it  lies  on  a,  thorax  sharply  deformed,  and  become  convex  backward. 

The  clavicle,  whose  first  function  is  to  keep  the  scapula  at  a  certain 
distance  from  the  sternum,  also  changes  according  to  the  situa- 
tion of  the  spinal  curve,  and  may  be  found  more  sharply  curved  in 
scoliosis. 

PELVIS 

Sacnim. — In  low  curves  (generally  convex  to  the  left  in  the  lumbar 
region)  the  sacrolumbar  junction  becomes  practically  the  apex  point, 
and  here  one  looks  for  rotation,  and  pressure  changes.     The  sacrum 

1  Fauconnet    "Zeitsch.  f.  orth.  Chir.,"  xvii,  page  201. 


PELVIS 


93 


i^  affected  in  such  low  lateral  curves  in  a  way  analogous  to  that  of  the 
other  vertebrae,  but  modified  in  extent  by  its  fixed  position.  In  a 
right  dorsolumbar  curve  the  following  changes  in  the  sacrum  were 
found  and  may  be  taken  as  exemplifying  them  (Schulthess) : 

1.  A  decrease  in  the  height  of  the  first  sacral  vertebra  on  the  con- 
cave side  {cf.  wedge  vertebra). 

2.  A  broadening  of  the  base  of  the  sacrum  on  its  concave  side  icf. 
broadening  of  concave  side  of  vertebral  body). 

3.  Forward  displacement  of  the  left  or  concave  half  with  its  cor- 
responding ala  and  backward 
displacement   of   the   right   or 
convex    half    {cf.    rotation    of 
vertebral  bodies). 

4.  Broadening  of  the  part 
of  the  sacrum  corresponding 
to  the  pedicle  on  the  concave 
side. 

5.  Lowering  of  the  arch  on 
the  concave  side. 

In  addition  to  this  there  is 
to  be  seen  at  times  a  slight  in- 
dication of  a  lateral  curve  of 
the  sacrum,  reaching  its  apex 
at  or  below  the  middle  of  the 
bone.  In  this  the  coccyx  may 
share,  emphasizing  the  curve, 
but  the  sacral  curve  is  most 
easily  seen  by  sighting  along  the  anterior  surface  of  the  sacrum  or 
looking  down  the  vertebral  canal.  This  curve  shows  slight  indi- 
cations of  the  same  changes  noted  in  the  presacral  vertebrae. 

The  pelvis  is  somewhat  changed  in  diameter  and  shape  in  severe 
low  lumbar  curves  in  which  the  sacrum  shows  distortion.  In  a  left 
lumbar  curve  the  diagonal  diameter  from  the  left  side  behind  to  the 
right  side  in  front  is  greater  than  the  opposite  diagonal;  thus,  in  an 
individual  case  of  right  dorsal  left  lumbar  curve  the  thorax  and  pelvis 
would  be  twisted  in  opposite  directions. 


Fig.  71. — Oblique  Pelvis  Accompanying 
Scoliosis. — (^Warren  Museum,  cast  from  a 
specimen  in  Musee  Dupuytren,  Paris.) 


SKULL 


In  long-continued  scoliosis,  especially  of  the  upper  part  of  the 
column,  asymmetry  of  the  face  and  skull  may  exist. 


94  PATHOLOGY 

INTERNAL  ORGANS 

In  scoliosis,  especially  in  moderate  and  severe  forms,  a  shortening 
of  the  trunk  is  apparent  which  prevents  the  normal  development  and 
function  of.  the  internal  organs.  By  the  lateral  displacement  of  the 
trunk  and  rotation  of  the  thorax  the  pleural  and  abdominal  cavities 
become  distorted.  The  patients  become  anemic  and  show  a  certain 
disposition  to  tuberculous  pulmonary  diseases.  Bachmann,^  in  197 
autopsies  in  scoliotic  patients  of  moderate  and  severe  type  has  found 
in  28.3  per  cent,  tuberculous  disease  of  the  lungs,  while  in  milder  de- 
grees of  scoliosis  there  were  66  per  cent,  so  affected. 

The  secondary  changes  in  the  internal  organs  are  essentially  de- 
pendent upon  the  narrowing  of  the  containing  cavities.  In  a  severe 
right  dorsal  curve  the  right  pleural  cavity  is  very  much  narrowed — so 
much  so  that  in  extreme  cases  the  inner  surfaces  of  the  ribs  are  found 
lying  close  to  the  vertebral  column.  The  narrowing  of  the  pleural 
cavity  on  the  left,  that  is,  on  the  concavity,  is  not  so  important  as 
that  of  the  right.  It  follows  that  the  right  lung  must  suffer  from  the 
distortion  more  than  the  left.  Mosse^  found  apex  infiltration  in  60.2 
per  cent,  of  100  scoliotic  children  between  five  and  sixteen  years  old. 
Kamine  v.  Zade^  found  apex  affections  in  73  per  cent,  of  scoliotic 
women,  the  lung  affection  being  predominantly  of  the  lung  on  the 
convex  side  of  the  curve. 

Affections  of  the  pleura,  adhesive  pleuritis,  leading  to  total  oblit- 
eration of  the  pleura  and  atelectasis,  are  found  very  frequently. 

Undoubtedly  the  lungs  of  scoliotic  patients,  especially  in  cases  of 
kyphoscoliosis,  are  predisposed  toward  a  greater  number  of  diseases 
than  the  lungs  of  normal  individuals. 

Heart  and  Vessels. — -The  same  narrowing  of  thoracic  space  affects 
the  heart.  It  is  frequently  found  pushed  upward  and  pressed 
against  the  anterior  chest-wall,  and  it  is  at  the  same  time,  according 
to  the  direction  and  the  extent  of  the  curvature,  more  or  less  dis- 
placed laterally.  In  right  curves  generally,  the  heart  is  displaced 
toward  the  left;  but  this  is  not  a  constant  condition.  Hypertrophy 
and  dilatation  of  the  cavities  of  the  heart  are  very  frequent,  espe- 
cially of  the  right  heart  in  severe  scoliosis.     Bachmann  found  it  in 

56.4  per  cent,  of  cases,  while  the  left  heart  was  similarly  affected  in 

17.5  per  cent.     This  phenomenon  was  found  in  both  right  and  left 
sides  in  25.9  per  cent. 

1  Bachmann:  "Bib.  med.,"  Abt.  i,  Heft  4,  1899. 
^  Mosse:  "Zeitsch.  f.  klin.  Med.,"  xli,  pages  1-4. 
^  Kamine  v.  Zade:  "Deut.  Arzte.  Zeit.,"  1902,  xx. 


INTERNAL   ORGANS  95 

The  aorta  in  general,  follows  the  curvature  of  the  spine,  particularly 
in  right  curves.  In  a  left  dorsal  curve,  however,  the  aorta  does  not, 
as  a  rule,  He  on  the  convex  side  of  the  curve,  but  runs  straight  like 
the  chord  of  an  arc,  more  often  in  front  or  even  a  very  little  to  the 
right  of  the  spine.  The  large  veins  show  less  typical  changes.  The 
vena  cava  in  the  region  of  the  liver,  where  it  is  relatively  fixed,  and 
occasionally  at  the  entrance  of  the  renal  veins,  may  show  a  change  in 
its  course  corresponding  to  the  change  of  position  of  the  organs. 

The  most  reasonable  explanation  for  the  hypertrophy  of  the  heart 
is  the  insufi&cient  depth  of  respiration  of  scoliotic  patients.  Even  in 
relatively  shght  distortion  of  the  thorax,  respiration  is  more  shallow 
than  the  normal,  consequently  the  right  side  of  the  heart,  in  order  to 
push  the  necessary  amount  of  blood  through  the  lungs,  must  do  an 
extra  amount  of  work. 

If  the  scoliosis  increases,  the  chest  space  is  restricted  still  more,  and 
the  expansion  of  the  lungs,  already  damaged  by  adhesions  and  thick- 
ening, is  impeded.  The  heart  is  also  pressed  against  the  front  wall  of 
the  chest,  and  the  blood-pressure  is  changed  on  account  of  the  bends 
in  the  vessels,  which  conditions  add  greatly  to  the  work  of  the  heart. 
The  difficulty  which  the  blood  finds  in  passing  through  the  lungs  leads 
to  a  great  degree  of  venous  dilatation  if  the  condition  continues  long 
enough.  This  is  especially  noticeable  in  the  veins  of  the  head,  neck, 
and  arms. 

Esophagus. — In  general  the  esophagus  has  a  tendency  to  deviate 
in  the  direction  of  the  concavity  of  the  curve,  although  frequently  its 
form  and  course  are  but  little  changed.  The  influence  upon  the 
course  of  the  esophagus  is  least  when  the  radius  of  the  curve  is  a  large 
one  and  the  secondary  curve  lies  below  the  diaphragm.  In  every 
case  the  esophagus  follows  a  straighter  course  than  the  aorta,  and  it 
crosses  the  aorta  near  the  point  at  which  it  pierces  the  diaphragm.^ 

Intestines. — The  abdominal  contents  are,  in  consequence  of  re- 
stricted space,  pressed  downward  and  forward,  and  added  to  this  is 
the  influence  of  the  approximation  of  the  chest  to  the  pelvis  and  the 
side  displacement  of  the  vertebral  column.  The  downward  pressure 
results  in  crowding  the  intestines  into  the  true  pelvis.  The  lateral 
displacement  of  the  thorax  affects  chiefly  the  transverse  colon,  which 
may  become  almost  vertical. 

Liver. — In  right  curves  the  liver  is  pushed  toward  the  left,  the  left 
half  is  better  developed  than  the  right  half,  and  finally  the  organ  on 
the  right  side  may  be  indented  by  the  ribs. 

1  Hacker:  "Wien.  med.  Woch.,"  1887,  page  46. 


g(>  PATHOLOGY 

Kidneys. — ^In  right  dorsal  scoliosis  the  right  kidney  is  often  dis- 
placed upward  along  the  spine  and  the  left  one  downward,  and  while 
the  right  kidney  suffers  as  a  rule  slight  changes,  the  left  is  more  likely 
to  be  affected  severely  from  rib  pressure.  Cystic  degeneration  and 
floating  kidney  are  common.  Bachmann  enumerates,  among  i8o 
observations,  14  cystic  kidneys,  31  cases  of  granular  atrophy,  18  cases 
of  simple  atrophy,  and  6  cases  of  hydronephrosis. 

Spleen. — The  spleen  may  be  higher  than  normal.  Perisplenitis, 
atrophy,  and  cyanotic  induration  have  been  observed  (Bachmann). 

Stomach. — The  position  of  this  is  influenced  by  that  of  the  liver 
and  duodenum.  The  pylorus  is  depressed,  while  the  cardiac  end 
generally  lies  high. 


CHAPTER  VIII 
ETIOLOGY 

The  subject  of  the  etiology  of  scoliosis  easily  lends  itself  to  elabora- 
tion and  in  discussing  it  there  is  difficulty  in  preserving  simpHcity. 
It  will  clear  matters  very  much  to  remember  that  there  are  two  types 
of  scoliosis,  one  the  postural,  better  spoken  of  as  false  scoliosis  which 
is  really  only  faulty  attitude  and  has  its  own  causes,  and  second,  the 
structural  or  true  scoliosis  where  there  is  pathological  change  in  the 
vertebr£e,  and  where  a  different  set  of  causes  must  be  looked  into. 
That  false  scoliosis  passes  into  true  scoliosis  at  times  has  been  already 
mentioned,  but  that  not  all  true  scoliosis  originates  in  false  scohosis 
is  also  undoubted. 

In  real  scohosis  there  are  met  many  cases  so  severe  that  they  can- 
not be  accounted  for  by  the  assumption  that  they  are  the  natural 
result  of  the  maintenance  of  a  growing  normal  spinal  column  in  a 
malposition  over  a  period  of  years,  and  one  must  look  for  an  addi- 
tional cause.  These  causes  are  as  a  rule  to  be  found  in  (a)  congenital 
anomahes  of  the  spine  and  its  appendages;  (6)  rickets;  (c)  empyema; 
(d)  infantile  paralysis,  and  {e)  cases  where  the  deformity  of  the  bones 
is  so  great  that  one  must  assume  the  existence  of  a  diminished  indi- 
vidual resistance  of  bone.  In  the  last  class  of  cases  many  writers 
would  assume  in  all  instances  the  existence  of  rickets  as  explaining 
the  softness  of  the  bones,  but  as  in  many  of  the  cases  evidences  of 
rickets  are  not  to  be  found,  it  seems  fairer  to  meet  the  situation  by 
the  statement  that  there  is  apparently  a  diminished  resistance  of 
bones  in  such  cases  of  unknown  origin,  but  that  no  demonstrable 
evidences  of  rickets  are  present. 

As  a  practical  application  of  the  foregoing  one  may  assume  that  a 
short  leg,  e.g.,  will  cause  asymmetry  and  faulty  attitude,  i.e.,  false 
scoliosis,  and  in  certain  cases  may  be  apparently  accountable  for  mild 
degrees  of  real  scoliosis,  but  that  it  is  not  competent  to  cause  a  mod- 
erate or  severe  scoliosis  in  a  child  whose  bones  possess  a  normal  resist- 
ance to  pressure,  but  if  the  bones  do  not  possess  this  resistance 
because  of  rickets  or  for  causes  that  we  do  not  at  present  recognize,  it 
or  any  similar  cause  may  result  in  moderate  or  severe  scoliosis. 
7  97 


98  ETIOLOGY 

The  following  conventional  schematic  representation  of  the  causes 
of  scoliosis  is  to  be  interpreted  in  the  light  of  what  has  just  been 
said. 

A.  Congenital  scoliosis. 

1.  Malformation  of  the  spine 

2.  Malformation  of  the  scapula. 

3.  Malformation  of  the  thorax. 

4.  Deforming  intrauterine  pressure. 

5.  Paralysis  of  intrauterine  origin. 

B.  Acquired  scoliosis. 

1.  Anatomical,  physiological,  or  other  asymmetries  elsewhere 

than  in  the  spine. 

(a)  Torticollis  (wry-neck). 

(b)  Pelvic  asymmetry. 

(c)  Pelvic  obliquity  (short  leg). 

(d)  Unequal  vision. 

(e)  Unequal  hearing. 

2.  Pathological  affections  of  the  vertebrae. 

(a)  Rickets. 

(b)  Osteomalacia. 

(c)  Pott's  disease. 

(d)  Dislocation. 

(e)  Arthritis  deformans. 
(/)  Tumors,  etc. 

3.  Pathological  affections  of  the  bones  and  joints  of  the  ex- 

tremities, causing  asymmetrical  position. 

(a)  Diseases  of  bones  and  joints  of  the  leg. 

(b)  Diseases  of  bones  and  joints  of  the  arm.  • 

4.  Distorting  conditions  due  to  disease  of  the  soft  parts. 

(a)  Infantile  paralysis. 

(b)  Spastic  paralysis. 

(c)  Nervous  diseases  (hemiplegia,  syringomyelia,  etc.) 

(d)  Empyema. 

(e)  Organic  heart  disease. 
(/)    Scars. 

(g)   Throat,  abdominal  or  pulmonary  disease. 
(h)  Acute  or  chronic  inflammation  of  the  spinal  mus- 
cles (lumbago,  etc.). 

5.  Habit  or  occupation. 


SCOLIOSIS    OF    CONGENITAL   ORIGIN  99 

A.  SCOLIOSIS  OF  congp:nital  origin 

The  tendency  of  the  last  few  years  has  been  very  strongly  toward 
the  recognition  of  the  congenital  type  of  scoliosis.  In  former  years 
practically  all  cases  were  regarded  as  acquired  and  the  congenital 
form  considered  as  a  great  rarity,  but  this  condition  is  coming  to  be 
recognized  as  by  no  means  infrequent,  and  every  year  an  increasing 
number  of  the  moderate  and  severe  types  are  being  transferred  from 
the  acquired  to  the  congenital  class.  This  is  due  largely  to  the  devel- 
opment of  the  x-rsLy  and  the  study  of  the  living  spine  thus  made 
possible. 

In  certain  congenital  cases  of  marked  scoliosis  where  a  careful 
study  of  the  spine  is  possible,  no  congenital  anomaly  is  to  be  found 
and  intrauterine  pressure  as  formulated  by  Hoffa^  is  the  presumable 
cause.  Intrauterine  paralysis  is  suggested  as  a  cause  by  a  case  of 
Hirschberger.^ 

In  the  majority  of  cases  congenital  scoliosis  is  due  to  defective 
formation  of  the  vertebrae  or  adnexa.  The  period  at  which  these 
defects  originate  is  discussed  by  Kirmisson,^  Mouchet,^  and  Seibert,^ 
the  rib  defects  being  secondary  according  to  the  view  of  the  former. 

I.  DUE  TO  MALFORMATIONS  OF  THE  VERTEBRAL  COLUMN 

Scoliosis  may  occur  as  a  congenital  condition  in  connection  with 
severe  rnalformations,  such  as  rachischisis  and  the  like.^  It  occurs 
also  as  the  result  of  less  severe  spinal  defects,  such  as  cervical  ribs, 
spina  bifida,  and  abnormal  formation  of  the  last  lumbar  vertebra. 

Congenital  scoliosis  may  be  evident — (i)  immediately  after  birth, 
as  in  the  case  of  the  severest  malformations  (Colville^  in  1015  cases 
of  new-born  children  found  one  case  of  scoliosis);  or  (2)  only  when 
the  child  begins  to  walk,  in  the  case  of  malforn\ations  not  severe 
enough  to  cause  a  curve  in  the  recumbent  position.  In  these  latter 
cases  the  curvature  appears  as  the  result  of  the  superincumbent 
weight  coming  upon  the  defective  spine  or  as  the  result  of  asym- 
metrical growth  due  to  the  malformation.     Such  cases  as  these  are 

^  "Lehrbuch  der  orth.  Chir.,"  1894. 
2  "Ztsch.  f.  orth.  Chir.,"  vii,  i. 
^  "Revue  d'Orth.,"  1910,  21. 
*  "Revue  d'Orth.,"  1910,  No.  4. 
^  "Ztsch.  f.  o.  Chir.,"  191 1,  xxviii,  415. 

6  Schmidt:  "AUg.  Path,  und  path.  Anat.  d.  Wirbelsaiile,"  Liibersch's  "Ergeb. 
zur  allg.  Path.,"  4,  Jahrg.,  1897. 
^  Colville:  "Rev.  d.  Orth.,"  1896,  7. 


lOO 


ETIOLOGY 


perhaps  not  slriclly  congenital,  but  might  be  better  spoken  of  as 
scoliosis  due  to  a  congenital  cause. 

Another  common  location  of  congenital  defects  is  in  the  cervico- 
dorsal  region  (Fig.  53).  The  formation  of  a  cervical  rib  is  often 
associated. with  a  splitting  of  the  vertebral  bodies,  as  shown  by  the 
.r-ray,  and  in  some  cases  the  cervical  rib  is  accompanied  by  a  rudi- 
mentary extra  vertebral  body.^     The  shoulder  on  the  side  of  the 

cervical  rib  is  elevated,  and  the 
curve  is  a  sharp  cervicodorsal 
one  with  a  compensatory  oppo- 
site curve  below.  Cervical 
ribs  may  or  may  not  be  ac- 
companied by  scoliosis.  In 
thirty-five  preparations  and 
eleven  clinical  cases  with  cer- 
vical ribs  Eckstein"'  twice  found 
scoliosis. 

At  the  lumbo-sacral  junc- 
tion anomalies  are  frequent.^ 
Waldeyer  found  that  the  first 
sacral  vertebra  possessed  lum- 
bar characteristics  in  thirty- 
three  out  of  265  cases,  and  in 
eighty-three  cases  of  Adolphi 
(48  men  and  35  women)  the 
twenty-fifth  vertebra  was  the 
last  pure  lumbar  in  3.6  per 
cent.,  the  twenty-fourth  in  92.8 
per  cent.,  and  the  twenty- third 
in  3.6  per  cent.  Abnormalities 
of  the  sacral  vertebrae  are  dis- 
cussed by  Breuss  and  Kolisko.* 

Sacralization  ofthefijth  lumbar  vertebra,  especially  if  unilateral,  is  a 
competent  cause  of  scoliosis.  °  Numerical  variation  of  the  vertebrae, 
especially  if  unilateral  as  pointed  out  by  Bohm,^  is  a  competent  cause 

1  Drehmann:  "Verhdl.  d.  Deutsch.  Gesell.  f.  orth.  Chir.,"  5th  Congress,  1906, 
page  12. 

-  "Zeitsch.  f.  orth.  Chir.,"  1908,  xx,  177. 

3  Cramer:  "Verhdlungen  d.  Deutsch.  Geo.  f.  orth.  Chir.,"  1908,  68. 

4  "  Pathologische  Beckenformen." 

5  Adams:  "Am.  Journ.  of  Orth.  Surg.,"  July,  1914. 

6  'Boston  Med.  and  Surg.  Jour.,"  Nov.  22,  1908;  "Berl.  klin.,  Wchsft.,"  1910, 
2;  "Berliner  Klinik,"  Feb.,  1910. 


Fig.  12.- — Scoliosis  Due  to  Congenital 
Defects  in  Spine  and  Thorax,  the  Ribs 
BEING  Bifurcated  and  Defective. 


MALFORMATION   OF    THE    SCAPULA   AND    THORAX 


lOI 


of  scoliosis;  but,  as  shown  by  Adams,  numerical  variation  is  not  as  a 
rule  accompanied  by  scoliosis  because  in  the  Dwight  collection  of 
sixty-four  spines  in  the  Warren  Museum  of  the  Harvard  Medical 
school,  all  showing  numerical  variation,  there  were  only  seven  which 
could  possibly  be  classed  as  scoliotic.^ 

Melting  together  of  vertebral  bodies  and  the  absence  of  part  of  a 
vertebra  are  the  chief  remaining 
causes   of   congenital   scoliosis 
so  far  formulated. 

2.  MALFORMATIONS    OF    THE 
SCAPULA 

Congenital  elevation  of  the 
scapula  (Sprengel's  deformity) 
will  cause  a  scoliosis  which  is 
usually  a  high  cervicodorsal 
curve  with  compensating  dor- 
solumbar  curve.  One  scapula 
is  occasionally  absent  or  mal- 
formed (Fig.  73). 

3.  MALFORMATION   OF   THE 
THORAX 

Occasionally  great  irregu- 
larity characterizes  the  ribs  of 
one  or  both  sides.  Some  may 
be  bifurcated,  others  are  united 
by  a  bridge  of  bone,  while  in 
others  certain  ribs  are  missing, 
scoliosis. 

Heredity  must  also  be  considered,  as  it  is  known  that  scoliosis  is 
apparently  inherited  in  some  families,  Schulthess  estimating  that 
from  10  to  15  per  cent,  of  scolioses  are  hereditary.  Congenital 
defects  of  form  can  be  inherited,  and  would  reasonably  lead  to  similar 
forms  of  scoliosis,  while  an  inherited  weak  skeleton  or  a  disposition  to 
rickets  would  not  necessarily  lead  to  a  reproduction  of  the  form  of 
scoliosis.  There  are  cases,  however,  in  which  the  form  also  seems  to 
be  hereditary. 


Fig. 


73. — Congenital   Elevation   of   the 
Scapula   Causing   Scoliosis. 


Such  irregularities  are  a  cause  of 


'  "Boston  Med.  and  Surg."  Jour.,"  Apr.  28,  1910. 


I02  ETIOLOGY 

B.  ACQUIRED  SCOLIOSIS' 

Scoliosis  is  to  be  classed  as  acquired  when  the  deformity  comes  on 
after  birth  from  some  cause  not  apparently  congenital,  and  this 
includes,  so-  far  as  we  know  now,  the  greater  number  of  cases.  The 
experimental  production  of  scoliosis  in  animals  has  been  demon- 
strated and  is  discussed  elsewhere  (page  48).  The  acquired  varieties 
of  scoliosis  may  be  considered  as  follows: 

I.  ANATOMICAL  OR  PHYSIOLOGICAL  ASYMMETRIES  ELSEWHERE 
THAN  IN  THE  SPINE 

(a)  Torticollis, — or  wry-neck,  a  condition  characterized  by  the  con- 
traction of  one  sternocleidomastoid  muscle,  causes  a  tilted  and 
twisted  position  of  the  head  and  necessitates  a  compensatory  lateral 
curve  of  the  spine  to  preserve  the  balance  and  enable  the  head  to 
assume  a  more  normal  position.  Unilateral  torticollis,  if  sufficiently 
long  continued,  is  always  accompanied  by  scoliosis. 

{b)  Asymmetry  of  the  Pelvis. — The  spine  is  not  always  located  in 
the  middle  of  the  pelvis,  but  at  times  is  found  at  one  side  of  the 
median  sagittal  plane  of  the  body  (amesiality  of  the  pelvis).  The 
pelvis  may  be  in  other  respects  asymmetrical.  In  these  cases  a 
compensating  lateral  curve  is  necessary  in  order  to  allow  the  head 
to  be  held  over  the  center  of  the  body^  (Fig-  74)- 

Hasse^  held  that  he  had  rarely  seen  a  symmetrical  pelvis,  and 
Naegele  in  a  collection  of  fifty  pelves,  could  not  find  one  to  show  to 
his  students  as  normal. 

(c)  Obliquity  of  the  Pelvis. — Any  condition  which  causes  the 
pelvis  to  be  held  higher  on  one  side  in  the  horizontal  plane  is  a  com- 
petent cause  of  scohosis,  because  such  obliquity  necessitates  a  lateral 
curve  of  the  spine  to  secure  normal  balance.  A  short  leg  must 
therefore  be  counted  as  a  possible  cause  of  scoliosis.  But  it  must  be 
remembered  that  a  difference  in  the  length  of  the  legs  is  very  common 
in  children,^  and  that  the  frequency  of  permanent  scoliosis  is  much 
less  than  the  frequency  of  short  legs  (Fig.  75).  The  association  of 
short  legs  and  scoliosis  has  been  investigated,  with  varynig  results; 
and  Schulthess  estimates,  without  analyzing  his  cases,  that  from  i  to 
5  per  cent,  show  this  association.  The  measurement  taken  with  a 
tape-measure  from  the  two  anterior  superior  spines  to  the  inner 
malleoli  while  the  patient  lies  on  the  back  is  inexact  and  of  little 

1  "Arch.  f.  Anat.  and  Phys.,"  1801. 

^  "Das  Schrag.  verengte  Becken.,"  1839. 

^  Bradford  and  Lovett:  "Orth.  Surgery,"  3d  ed.,  page  476. 


SCOLIOSIS    CAUSED   BY   ASYMMETRY 


103 


value  as  determining  the  real  position  of  the  pelvis  in  standing,  and 
much  importance  must  not  be  attached  to  it.  The  most  reliable 
method  that  we  have  of  determining  the  horizontal  plane  of  the 
pelvis  and  the  obliquity  which  must  exist  when  there  is  really  a 
short  leg  is  to  make  level  the  two  anterior  superior  spines  when  the 

patient  stands  erect  by  means  of 
pieces  of  thin  board  placed  under 
one  foot,  but  even  this  is  inac- 
curate on  account  of  the  fre- 
quency of  asymmetry  of  the  pelvis 
just  alluded    to.     It  is  an  occa- 


FiG.  74. — Scoliosis  Due  to  Asym- 
metry OF  THE  Pelvis,  the  Right 
Side  Being  Smaller. 


Fig.  75. — Left  Lumbar  Scoliosis 
from  Inequality  in  the  Length  of 
Legs. 


sional  experience  to  find  that  the  spinal  curve  is  increased  by 
putting  a  block  under  the  foot  on  the  side  shown  to  be  short  by 
measurement,  and  that  the  spinal  curve  is  thus  improved  by  mak- 
ing the  long  leg  longer. 

(d)  Unequal  hearing  causes  a  tilting  or  twisting  of  the  head  which 
may  produce  a  temporary  lateral  curve  in  the  cervical  and  upper 
dorsal  regions. 


I04  ETIOLOGY 

(e)  Unequal  vision,  necessitating  a  tilting  of  the  head  to  bring 
vertical  objects  into  clearer  vision,  may  cause  a  lateral  curve.  The 
school  observations  at  Lausanne  are  of  interest  in  this  connection,  as 
a  steady  increase  in  the  percentage  of  scoliotic  and  myopic  children 
was  found  from  the  lowest  classes  upward,  as  is  shown  by  the  table. 

Class  Scoliotic  [Myopic 


1 8.7  per  cent.       3 

II 18.2  "  4 

III 198  "  5 

IV .27.2  "  6 

V 28.3  "  8 

VI 32.4  "  13 

VII 31.0  "  19 


o  per  cent. 
5         " 


The  relation  between  scoliosis  and  myopia  has  not  yet  been  deter- 
mined. 

It  is  obvious  that  astigmatism  may  be  a  cause  of  head  tilting.  The 
subject  has  been  carefully  worked  out  by  Gould, ^  whose  conclusion 
is  that  in  asymmetrical  astigmatism  the  axis  of  the  dominant  eye 
determines  a  tilting  of  the  head  to  the  right  or  left,  but  that  this 
does  not  occur  in  symmetrical  astigmatism. 

But  it  must  be  remembered  that  those  conditions  which  cause  the 
spine  to  be  held  asymmetrically,  and  which  have  just  been  men- 
tioned, are  frequent,  while  structural  scoliosis  is  not  b}^  any  means  so 
frequent.  And  one  must  assume  that  in  those  cases  where  severe 
or  moderate  structural  changes  have  occurred  as  a  result  of  this 
asymmetrical  position  that  the  bones  of  the  individual  possess  less 
than  normal  resistance. 

2.  PATHOLOGICAL  AFFECTIONS  OF  THE  VERTEBR.E 

(a)  Rickets,^  which  is  a  constitutional  disease  beginning  in  the 
first  dentition  which  leads  to  a  softening  of  the  bones,  has  long  been 
recognized  as  a  cause  of  scoliosis.  But  the  trend  of  recent  opinion  is 
toward  assigning  rickets  as  a  cause  of  scoliosis  in  a  very  much  larger 
number  of  cases  than  was  formerly  done.  Indeed,  some  writers 
would  go  so  far  as  to  assume  that  practically  all  organic  scoliosis,  not 
obviously  due  to  a  congenital  defect  or  some  such  obvious  cause  as 

1  G.  M.  Gould:  "Amer.  Medicine,"  May  21,  1904;  Mar.  26,  1904;  April  8, 
1905;  "N.  Y.  Med.  Record,"  Apr.  22,  1895.  H.  A.  Wilson:  "N.  Y.  :\Ied.  Journal," 
June,  1906. 

^Kirsch:  "Verhdlg.  d.  Deuts.  Ges.  f.  orth.  Chir.,"  1910,  page  94;  Bohm: 
"Verhdlg.  d.  Deuts.  Ges.  f.  orth.  Chir.,"  1910,  page  49. 


PATHOLOGICAL   AFFECTIONS    OF   THE  VERTEBRA 


lO: 


empyema  or  paralysis,  was  due  to  rickets.     The  situation  in  this 
regard  has  been  already  discussed  at  the  opening  of  the  chapter. 

The  typical  rachitic  variety  of  scoliosis  is  characterized  by  a  sharp 
and  severe  curve  oftenest  in  the  lower  spine,  with  shortening  of  the 
trunk.  It  is  one  of  the  most  resistant  forms  to  treatment  and  is  a 
variety  which  begins  early  as  the  softness  of  the  bones  is  most  marked 
during  the  acute  process.  The  recognition  is  made  by  the  presence 
of  the  other  signs  of  rickets  found  in  the  deformed  bones  elsewhere 
and  by  the  usual  diagnostic  signs. 

(b)  Osteomalacia,  an  uncommon  process  like  rickets  in  causing  a 
softening  of  the  bones,  but  more  frequently  seen  in  adolescents  and 
adults  than  in  children,  is  ac- 
companied     occasionally      by 
lateral  curvature. 

(c)  Tuberculous  disease  of 
the  spine,  or  Pott's  disease,  is 
a  destructive  pathological  proc- 
ess attacking  the  bodies  of 
the  vertebrae.  Lateral  devia- 
tion of  the  spine  associated 
with  stiffness  often  exists  in 
connection  with  the  backward 
"hump"  or  kyphosis,  which  is 
the  characteristic  sign  of  the 
disease.  This  early  form  is 
generally  atypical,  with  little 
rotation.  In  the  early  stages 
of  Pott's  disease,  lateral  devia- 
tion is  present  as  a  symptom  of  irritation.  In  the  later  stages  of 
Pott's  disease  lateral  asymmetry  may  be  present  as  the  result  of 
unilateral  destruction  of  one  or  more  of   the   diseased  vertebra. 

(d)  Severe  injuries  of  the  spine,  resulting  in  chronic  sprain  of  the 
vertebral  column,  dislocation  of  the  vertebras,  and  injury  of  the  epi- 
physeal cartilage,  may  be  accompanied  by  lateral  deviation  of  the 
spine  as  a  symptom. 

{e)  Arthritis  deformans  is  characterized  by  a  progressive  stiffening 
of  the  spine  due  to  deposits  of  newly  formed  bone  on  the  front  and 
sides  of  the  column,  binding  the  vertebrae  together.  The  interver- 
tebral discs  degenerate  and  the  vertebrae  become  fused;  bony  deposit 
occurs  in  the  ligaments,  and  the  articulations  of  the  vertebrae  with 
the  ribs  may  lose  some  or  all  motion.     Lateral  deviation,  accompa- 


FiG.  76. — Severe  Scoliosis  Due  to  Rickets. 


I06  ETIOLOGY 

nied  by  general  kyphosis,  is  generally  present,  but  is  atypical  and 
accompanied  by  little  rotation  (see  Ischias  Scoliotica,  page  io8). 

Other  causes  of  this  class  are  tumors  of  the  spine  and,  it  is  said, 
hereditary  syphilis. 

The  scolioses  of  this  class  are  symptomatic  of  a  serious  condition, 
and  except  for  that  of  rickets,  are  not  to  be  treated  like  ordinary  pri- 
mary scolioses  but  would  be  injured  by  sijch  treatment. 

3.  AFFECTIONS  OF  THE  BONES  AND  JOINTS  OF  THE  EXTREMITIES 

(a)  Diseases  of  the  bones  and  joints  of  the  lower  extremity 

play  a  larger  part  in  the  etiology  of  scoliosis  than  those  of  the  arm 
and  shoulder.  Lateral  curvature  may  be  caused  by  the  shortening  of 
one  leg  due  to  derangement  of  growth;  to  unilateral  diseases  of  the 
hip-joint  causing  shortening,  dislocation,  contraction,  or  ankylosis  in 
a  position  of  adduction,  abduction,  or  flexion;  to  unilateral  congenital 
or  paralytic  dislocation  of  the  hip;  to  coxa  vara,  coxa  valga,  and 
fractures  of  the  lower  extremity;  to  diseases  and  malformations  of 
the  diaphyses  of  the  leg  or  thigh  bones;  to  diseases  of  and  operations 
on  the  knee-joint  causing  shortening,  contraction  in  the  flexed  posi- 
tion, or  knock-knee  on  one  side;  and  to  diseases  and  malpositions  of 
the  foot,  especially  flat-foot. 

(b)  Diseases  of  the  shoulder-joint,  causing  partial  or  complete 
ankylosis,  may  be  accompanied  by  a  curve  of  the  spine  in  the 
dorsal  region. 

4-  DISTORTING  CONDITIONS  DUE  TO  DISEASE  OF  THE  SOFT 

PARTS 

(a)  Infantile  spinal  paralysis  or  anterior  poliomyelitis ^  is  a  com- 
mon cause  of  lateral  curvature.  The  paralysis  occurs  of  tenest  during 
early  childhood,  and  the  lower  extremity  is  more  often  affected  than 
the  upper.  The  deformities  produced  are  due  to  shortening  of  bone 
or  to  muscular  paralysis.     Scoliosis  results  in  one  of  three  ways: 

1.  From  inequality  in  the  length  of  the  legs,  causing  a  tilting  of  the 
pelvis. 

2.  From  Unilateral  paralysis  of  the  muscles  directly  controlling 
the  vertebral  column,  which  may  cause  a  deviation  of  the  spine 
either  to  that  side  or  to  the  other  side.  It  does  not  follow,  as  shown 
by  Arndt  experimentally  and  as  recognized  clinically  by  others,  that 

^  Cordet  Boise:  "Revue  d'Orthopedie,"  1910,  5,  381. 


PARALYTIC    SCOLIOSIS 


107 


a  paralysis  of  the  muscles  of  one  side  of  the  back  is  followed  by  a 
curve  convex  toward  the  paralyzed  muscles,  as  would  naturally  be 
expected.  The  curve  is  the  result  of  the  effort  of  the  patient  to  ad- 
just his  center  of  gravity  to  the  new  conditions  induced  by  unilateral 
paralysis.  This  equilibration  may  result  in  a  curve  convex  either 
to  the  right  or  left  in  a  right-sided  paralysis. 

3.  From  faulty  spinal  attitudes  assumed  in  consequence  of  paraly- 
sis elsewhere,  as  in  paralysis  of  the  arm. 


Fig.  77. — Right  Dorsal  Left  Dorso- 
LuMBAR  Curve  Due  to  Infantile 
Paralysis. 


Fig.   78. — ^Severe  Right  Curve  Due  to 
Infantile   Paralysis. 


(b)  Spastic  paralysis  or  Little's  disease  is  the  result  of  a  cerebral 
lesion  and  a  descending  degeneration  of  the  lateral  columns  of  the 
spinal  cord.  The  growth  of  bones  is  often  retarded,  and  muscular 
irritability  and  stiffness  are  noted  with  contractions.  Scoliosis  is  an 
occasional  accompaniment. 

(c)  Other  nervous  diseases,  represented  by  a  much  smaller  num- 
ber of  cases  accompanying  lateral  curvature,  are  multiple  neuritis, 
meningitis,  cerebrospinal  meningitis,  syringomyelia,  pseudomuscular 
hypertrophy,  locomotor  ataxia,  Friedreich's  ataxia,  tumors  of  the 
spinal  cord,  and  obstetrical  paralysis. 

A  marked  lateral  deviation  of  the  spine,  extensively  studied  by  the 


io8 


ETIOLOGY 


Germans  and  termed  by  them  Ischias  Sccliotica,^  is  a  form  without 
much  rotation  which  accompanies  the  inflammatory  affections  of  the 
lumbar  region  vaguely  classed  as  "lumbago"  and  "sciatica."  It  is 
frequently  found  in  arthritis  of  the  spine  and  in  acute  and  chronic 
sprains  of  the  spine. 

A   similar  malposition  is  observed  in  hysteria-   (Fig.   8i).     An 
analogous  deviation  is  found  in  disease  of  the  sacro-iliac  joint  in 


Fig.  79 — Severe  Right  Curve  (see  Fig. 
78)  Due  to  Infantile  Paralysis. 

Showing  abdominal  and  thoracic  con- 
struction on  left. 


Fig.  80. — Same  Case  as  Figs.  78  and 
79  Showing  Deformity  of  Lower  Rib. 
Induced  by  Pressure. 


which  the  lateral  curve  is  induced  by  the  instinctive  effort  to  spare 
the  affected  joint. 

{d)  Empyema^  is  followed  by  lateral  curvature  in  certain  cases, 
both  without  operation  and  after  the  operation  for  removal  of  a  rib. 
The  scar  contraction  seems  to  be  the  cause  of  the  chief  curve,  which  is 
always  to  the  right  in  left  empyema  and  vice  versa.  There  are  likely 
to  be  compensating  curves  above  and  below  the  main  curve,  the 


1  Stein:  "Zeitsch.  f.  orth.  Chir.,"  xxv,  1910,  479  (with  literature). 
-Binswanger:  "Hysterical  Scoliosis,"  "Deutsch.  med.  Wochens. 
beil.,  1902,  5. 

'Walther:  "Zeitsch  f.  orth.  Chir.,"  1910,  xxv,  401. 


Vereins- 


OCCUPATIONAL    SCOLIOSIS 


109 


height  of  the  shoulders  is  generally  very  different  and  the  hyper- 
trophy of  the  sound  side  of  the  chest  is  a  marked  feature  (Fig.  82). 

(e)  Scars  rarely  cause  scoliosis,  although  it  sometimes  is  found 
after  extensive  unilateral  burns  when  the  deviation  of  the  spine  is 
brought  about  by  contraction  of  the  scar  tissue  (Fig.  83). 

(/)  Phthisis  and  diseases  of  the  pleura  and  obstructions  in  the 
nasopharynx  are  to  be  mentioned  among  the  diseases  of  the  respira- 
tory organs  sometimes  followed  by  scoliosis. 


Fig.  81. — ^Hysterical  Scoliosis. 


Fig.  82. — Right  Dorsal  Curve  Due  to 

Left  Empyema. 


(g)  Organic  heart  disease,  especially  in  children,  is  a  competent 
cause  of  lateral  curvature  (Fig.  84). 


5.  HABIT  OR  OCCUPATION 

That  the  continued  maintenance  of  an  asymmetrical  portion  of  the 
spine  through  the  period  of  growth  may  result  in  some  degree  of 
bony  deformity  of  the  growing  spine  is  a  self-evident  proposition, 
dependent  on  the  fact  that  growing  bone  is  plastic  and  follows  the 
line  of  least  resistance.     But  that  such  conditions  are  likelv  to  result 


no 


ETIOLOGY 


in  moderate  or  severe  scoliosis  in  normal  children  is  not,  in  the  opinion 
of  the  writer,  likely.  That  they  may  result  in  "false  scoliosis"  or 
slight  scoliosis  is  apparently  reasonable  to  expect. 


Fig.  83. — -Scoliosis  Due  to  Extensive 
Burn  of  Left  Chest  Received  at  the 
Age  of  17.     Patient  now  19  Years  Old. 


Fig.  84. — Severe  Scoliosis  Associated 
WITH  Organic  Heart  Disease.  Death 
Occurred  from  the  Latter. 


The  commonest  causes  of  "occupation"  scoliosis  are  to  be  found 
in  children  in  the  assumption  of  faulty  attitudes  at  school  and  at 
home,  violin  playing,  the  use  of  a  side  saddle  in  horseback  riding, 
carrying  heavy  weights  asymmetrically,  etc. 

The  relation  of  scoliosis  to  school  life  has  been  much  discussed  and 
will  be  considered  by  itself. 


CHAPTER  IX 
OCCURRENCE 

Scoliosis  in  Quadrupeds.' — Scoliosis  in  animals  other  than  man 
has  been  observed,  but  is  rare.  Eighteen  cases  were  found  in  litera- 
ture by  Hartel  in  1909.  Ten  of  these  were  foetal  malformations 
found  in  new-born  horses,  goats,  deer,  and  calves;  curves  due  to 
rickets  were  found  in  pigs,  and  in  cattle  an  inflammation  and  growing 
together  of  vertebrae  or  parts  of  vertebrae.  Further  are  to  be  added 
scoliosis  in  a  colt  one  and  one-half  years  old  and  in  a  goat,  and  a  case 
of  scoliosis  due  to  congenital  defect  of  the  vertebrae  in  the  cervical 
region  in  a  horse. 

Such  curves  in  mammals  consist  of  short  sharp  curves  accom- 
panied by  torsion,  but  what  corresponds  to  real  "habitual  scoliosis" 
in  the  human  being  has  not  been  definitely  established  as  existing  in 
quadrupeds;  a  real  static  deformity,  however,  is  the  sway  back  ob- 
served in  horses.^ 

In  the  lower  vertebrates  scoliosis  has  been  observed  in  fishes, 
snakes,  and  eels.  Among  domestic  fowls  scoliosis  is  not  uncommon 
in  hens,  ducks  and  geese,  and  Klapp  and  Hartel  collected  a  dozen 
scoliotic  skeletons  from  this  source  in  one  year.  The  study  of  this 
deformity  in  fowls  has  a  certain  bearing  on  scoliosis  in  man  because 
of  the  fact  that  in  birds  the  weight  is  borne  on  two  limbs,  although 
the  position  of  the  spine  is  much  more  horizontal.  In  quadrupeds 
the  horizontal  position  of  the  spine  and  its  support  on  four  limbs 
makes  the  static  relations  wholly  different  from  those  existing  in  man. 

In  fowls  the  examinations  of  Hartel  show  two  distinct  classes  of 
cases:  first,  an  atypical  scoliosis  due  to  vertebral  defects  and  uni- 
lateral numerical  variation  of  the  vertebrae,  an  important  matter  as 
bearing  on  the  similar  condition  in  jxian;  and,  second,  a  typical 
scoliosis  accompanied  by  rotation  of  the  vertebral  bodies  to  the  con- 
vex side  of  the  curve,  which  is  more  frequent  than  the  first-named 
variety.  As  bearing  on  the  etiology  of  the  latter,  changes  attribu- 
table to  trauma,  inflammatory  processes,  and  rickets  were  absent 

1  Hartel:  "Deutsch.  Ztschft.  f.  Chir.,"  98,  277. 

2Rievel:  "Knockenpathologie  der  Tiere."  "Lubarschs  and  Ostertags  Erge- 
buisse,"  xi,  1907. 


112  OCCURRENCE 

in  the  ten  specimens  examined,  and  in  such  we  must  attribute  the 
cause  either  to  intra-uterine  pressure  or  to  purely  static  causes  arising 
late  in  life.  That  is  to  say,  we  must  assume  that  the  bones  of  the 
individual  fowl  possessed  less  than  normal  strength  and  yielded 
under  weight. 

In  quadrupeds,  therefore,  one  finds  as  causes  vertebral  anomalies, 
inflammation  of  bones,  and  rickets.  In  fishes  and  snakes  apparently 
the  first  named  of  these  three  causes,  and  in  fowls  vertebral  anoma- 
lies alone,  can  be  demonstrated  as  causes,  leaving  the  bulk  of  the 
cases  (ten  out  of  twelve)  to  be  accounted  for  as  deformities  due  to 
weight  acting  on  bones  of  less  than  normal  resistance.  Experiment- 
ally scoliosis  has  been  produced  in  animals  by  Wullstein,  Arndt,  and 
Ribbert. 

FREQUENCY 

Figures  with  regard  to  the  frequency  of  scoliosis  in  the  population 
as  a  whole  are  lacking,  except  for  some  figures  brought  forward  by 
Schanz.^  In  five  years,  of  189,000  recruits  available  for  the  German 
army  7.2  per  thousand  were  disqualified  for  spinal  curves  of  all  kinds; 
that  is,  less  than  i  per  cent.  Figures  with  regard  to  the  percentage 
of  scoliotics  in  hospital  practice  show  nothing  because  the  clientele  of 
various  hospitals  varies  so  largely.  Fortunately  there  are  figures 
relating  to  its  frequency  in  school  children  which  are  available,  which 
form  our  only  reliable  means  of  judging  its  frequency. 

It  is  evident,  however,  that  the  percentage  of  scoliotics  among  a 
number  of  school  children  examined  will  vary  with  the  point  of  view 
and  standard  of  the  observer,  and  this  is  shown  by  the  very  great  dis- 
crepancy shown  in  the  tables  commonly  quoted.  These  as  a  rule 
include  old  and  new  figures  from  all  over  the  world  from  observers  of 
every  degree  of  special  qualification.     Such  a  table  is  given  (Table  V) . 

The  very  careful  and  modern  investigations  of  Combe,  Scholder 
and  Weith,  Gronberg,'  Haglund,^  and  Lubinus*  seem  to  form  the 
safest  basis  for  conclusions.  According  to  these,  the  frequency  in 
girls  of  the  school  age  varies  from  10  to  23  per  cent,  and  of  boys  from 
16.4  to  26  per  cent.  * 

It  has  been  noted,  however,  that  the  percentage  varies  in  different 
localities  without  obvious  reasons,  Gronberg  finding  in  Abo  a  percent- 
age of  1 1.6,  while  in  the  neighboring  Finnish  city  of  Wiborg  similar 

1  "Verhdl.  d.  Deutsch.  Ges.  f.  orth.  Chir.,"  1910,  page  454. 

-  "Ztsch.  f.  orth.  Chir.,  xviii,  130. 

3  "Ztsch.  f.  orth.  Chir.,"  xxv,  649. 

''  "Verhdl.  d.  Deutsch.  Geo.  f.  orth.  Chir.,"  1910,  469. 


SEX 
Table  V 


113 


Boys 


Observer 


1864  Guillaune 

?     Hurliman 

1882  Mayer 

1885  Key 

1885  Drachmann 

1891  Wisser 

1892  Bardenheur        and 

Castenholz. 

1893  Brunner,       Klausner 

and  Seydel. 

1894  Krug 

?     Hagmann 

?     Kallbach 

1901  Combe,  Scholder  and 
Weith. 

1906  Silfwerskiold 

1907  Gronberg 

1910  Haglund 

1910  Lubinus 


Place 


No. 


Merchatel. 

Gug 

Furth 

Sweden. . . 
Denmark.  . 
Wurzburg. 
Cologne.  .  . 


Munich. 


Goteborg. . 
Wiborg. .  .  . 
Stockholm. 
Kiel 


350 


1.052 

569 

Dresden 695 

Moscow 

St.  Petersburg 
Lausanne 1,290 


11,210 

16,789 

280 


4,257 
819 

T,02I 


Scoliosis, 
per  centt 


15 


0.8-5.7 
0.8 

55 


6.2 

8.5 
26 


23 


II. 9 

13.2 


Girls 


No. 


381 

? 

3,072 
1,1386 

217 
439 

987 

489 

723 

1,664 

2,333 
1,024 


Scoliosis, 
per  cent. 


41 

22 

37 
10.8 

2 
45-6 
23 

8.2 

6.5 
22.5. 
29 
26 

26.7 


3,2341       12.8 
'4,093        22.1 


780 
2,204 


16.4 
18 


investigations  by  Gronberg  showed  34.5  per  cent,  of  scoliosis,  and 
Lubinus  found  in  Kiel  in  different  girls'  schools  of  the  same  grade  that 
the  percentage  of  scoliotics  varied  from  13. i  to  34.6  per  cent,  without 
assignable  cause.  This  has  nothing  to  do  with  the  variation  accord- 
ing to  age  to  be  discussed  later. 

SEX 

It  is  generally  the  opinion  that  in  adults  women  show  a  greater 
number  of  scolioses  than  men,  although  published  statistics  confirm- 
ing this  fact  do  not  exist.  Records  of  the  relative  frequency  of  sco- 
liosis in  adolescents  and  children  made  in  orthopedic  institutions 
where  patients  apply  for  treatment  show  a  very  much  larger  percent- 
age of  scolioses  among  girls  than  in  boys.  The  difference  between 
the  sexes  is  less  where  large  numbers  of  school  children  are  investi- 
gated, such  figures  showing  in  general  a  slightly  higher  percentage  in 
girls  than  in  boys.  To  explain  this  difference  we  must  either  assume 
that  boys  outgrow  scoliosis  or  that  they  do  not  come  to  the  institu- 
tions for  treatment  until  the  curves  become  severe  or  until  comphca- 


114  OCCURRENCE 

tions  arise,  while  in  girls  the  efifects  of  scoliosis  upon  the  figure  are 
perceptible  much  earlier,  and  treatment  is  sought  to  remedy  curves 
which  in  boys  would  pass  unnoticed  by  the  parents. 

The  table  which  follows  shows  the  great  preponderance  of  girls 
coming  to  institutions  for  treatment.  The  figures  for  the  proportion 
of  the  sexes  in  school  children  are  given  in  the  table  in  the  section 
on  Frequency. 

Figures  from  Institutions  where  Patients  are  Treated 

Boys,  Girls,  Boys,  Girls, 

per  cent,     per  cent.  per  cent,    per  cent. 

Eulenburg 13  87  Adams 12.8  87 

Ever 7  93  Scholder 14.8  85 

Ketch 17  83  Schanz 25  74.8 

Kolliker 20  80  Rosenthal 22  78 

Roth 8.5  91  Schulthess 14.2  85.5 

Wedberger 15.9  84  Redard 15.6  83.3 

Behrend 13.4  86  , 

AGE 

Scoliosis  is  an  afifection  of  the  years  of  growth  in  a  large  majority  of 
cases,  but  it  is  often  extremely  difi&cult  to  form  an  accurate  idea  of 
the  age  at  which  the  deformity  begins  in  individual  cases.  Scoliosis 
due  to  rickets,  infantile  paralysis,  and  congenital  causes  may  occur  up 
to  the  fifth  year.  In  general,  however,  the  inaccurate  observations  of 
parents  furnish  no  foundation  upon  which  to  base  theories  or  statis- 
tics concerning  the  time  of  the  beginning  of  the  scolioses  observed  in 
older  children.  The  relation  of  age  to  scoliosis  as  observed  in, the 
schools  will  be  discussed  later. 

In  regard  to  the  age  at  which  scoliotic  children  are  brought  for 
treatment,  Eulenburg  found  over  50  per  cent,  of  all  cases  between 
seven  and  ten  years  old,  and  but  10  per  cent,  between  the  ages  of 
ten  and  fourteen  years. 

The  clinical  material  collected  by  the  Institute  of  Liining  and 
Schulthess  at  Zurich  has  been  used  by  Sutter  and  Miiller  in  preparing 
curves  of  the  frequency  of  scoliosis  at  different  ages.  Miiller  finds  the 
greatest  number  of  cases  in  the  fourteenth  year.  The  number 
increases  gradually  from  the  eighth  to  the  fourteenth  year,  and 
decreases  rapidly  from  the  fourteenth  to  the  seventeenth  year. 
Sutter  found  that  the  number  of  boys  brought  for  treatment  reached 
the  maximum  in  the  ninth,  thirteenth,  and  fourteenth  years.  The 
number  of  cases  under  treatment  at  fourteen  years  of  age  is  double 


FREQUENCY   OF   DIFFERENT   FORMS  II5 

that  for  nine  years,  and  shows  not  only  an  increase  in  frequency  of 
scoliosis,  but  an  increase  of  deformity  in  curves  already  existing. 

RELATIVE  FREQUENCY  OF  THE  DIFFERENT  FORMS  OF  SCOLIOSIS 

Statements  concerning  the  frequency  of  the  simple  forms  of  scolio- 
sis are  of  very  recent  origin.  All  statistics  agree,  however,  in  show- 
ing that  for  all  forms  there  are  more  scolioses  convex  to  the  left  than 
to  the  right.  There  is  less  unanimity  as  to  which  of  the  single  forms 
is  the  most  frequent.  Lorenz  states  that  left  lumbar  scoliosis  is  the 
most  numerous.  Kolliker,  from  the  examination  of  721  cases,  finds 
the  simple  dorsal  scoliosis  the  most  frequent.  By  considering  the 
tables  of  other  investigators  Schulthess  found  the  compound  right 
dorsal  scoliosis  the  most  frequent  form,  followed  in  order  by  the 
simple  dorsolumbar  curves,  total  scoliosis,  and  lumbar  scoliosis. 
The  cervicodorsal  form  was  the  least  frequent. 

Among  the  571  school  children  with  lateral  curvature  out  of  2134 
children  examined  at  Lausanne,  401,  or  60.3  per  cent.,  showed  curves 
convex  to  the  left,  121,  or  21.1  per  cent.,  curves  convex  to  the  right, 
and  49,  or  8.6  per  cent.,  compound  curves.  The  table  compiled 
from  these  figures  shows  the  percentages  of  curves  as  to  their  form  and 
convexity.  The  total  curve  is  the  most  frequent  form  in  school 
children,  and  is  followed  by  the  left  and  right  lumbar  curves  and  by 
left  dorsal  scoliosis. 


Left  convex 

Right  convex 

Total 

Total  scoliosis. .  .   48 .  i  per  cent. 

7.8  per  cent. 

56      per  cent. 

Dorsal  scoliosis..     8.4      " 

4.3        " 

12.7        " 

Lumbar  scoliosis.   1 1 . 8      " 

8.5        " 

20.3        " 

Combined  scoliosis.               8 . 5  per 

cent. 

8.5        " 

Almost  the  only  records  that  have  been  studied  and  tabulated  for 
definite  study  are  those  of  the  Institute  of  Liining  and  Schulthess, 
and  it  is  from  these  investigations  that  much  of  the  following  mate- 
rial is  drawn. 

Age.— At  eight  years  the  left  scolioses  form  64  per  cent,  and  the 
right  scolioses  33  per  cent,  of  the  total  number  of  curves.  In  the 
fourteenth  year  the  number  of  curves  convex  to  the  left  and  right  is 
about  equal.  The  number  of  compensating  curves  increases  from  27 
per  cent,  in  the  eighth  year  to  45  per  cent,  in  the  seventeenth  year. 

Position  of  Apex  oj  Deviation. — To  ascertain  the  location  of  the 
point  of  maximum  deviation  Durrer  has  constructed  a  set  of  curves 
which  show  that  for  the  left  convex  scolioses  the  maximum  deviation 


Il6  OCCURRENCE 

is  at  the  dorsolumhar  junction,  and  for  the  right  convex  curves  the 
apices  are  found  in  the  region  of  the  seventh  dorsal  vertebra,  which 
showed 'a  much  greater  deviation  than  the  adjacent  vertebras,  while 
in  the  left  convex  curves  the  deviation  is  more  evenly  distributed 
over  the  length  of  the  spine. 

Schulthess  finds  four  principal  apices  of  deviation  for  single  and 
compound  forms  of  scoliosis:  (i)  The  upper  dorsal  region  to  the 
right;  (2)  the  dorsolumbar  junction  to  the  left;  (3)  the  upper  dorsal 
and  lower  cervical  regions  to  the  left;  (4)  the  lower  lumbar  region  to 
the  right. 

In  the  eighth  year  the  maximum  deviation  of  the  right  dorsal 
curves  is  in  the  region  of  the  sixth  to  the  eighth  dorsal  vertebrae,  and 
is  still  found  there  in  the  seventh  year.  The  apex  of  the  left  convex 
curves  in  the  eighth,  ninth,  and  tenth  years  is  at  the  ninth  or  tenth 
dorsal  vertebra;  between  the  ages  of  eleven  and  thirteen  it  is  found 
at  the  twelfth  dorsal  vertebra,  and  descends  to  the  first  or  second 
lumbar  vertebra  between  the  ages  of  fifteen  and  eighteen  years. 


CHAPTER  X 
THE  RELATION  OF  SCOLIOSIS  TO  SCHOOL  LIFE 

The  relation  that  school  conditions  bear  to  scoliosis  is  one  of  the 
most  important  questions  in  formulating  the  cause  of  scoliosis  and 
has  been  much  discussed  of  late.  It  is  important  to  examine  certain 
practical  aspects  of  the  question. 

School  Fatigue. — A  correct  attitude  is  dependent  upon  the  tone 
and  strength  of  the  muscles  by  which  the  upright  posture  is  main- 
tained, so  that  any  cause,  such  as  fatigue,  which  lowers  the  muscular 
tone,  has  a  bearing  in  this  connection. 

Mental  Fatigue. — Muscles  become  relaxed  not  alone  by  physical 
but  by  mental  exertion  and  mental  fatigue.^  Mental  work  is  at  first 
stimulating,  but  if  continued  for  a  long  time,  especially  concentrated 
on  one  topic,  will  produce  both  mental  and  bodily  fatigue. 

Continuous  mental  labor,  though  of  only  short  duration,  will  produce  a  greater 
degree  of  fatigue,  and  that  more  quickly,  than  the  same  amount  of  work  inter- 
rupted by  brief  intervals  of  rest.  A  change  of  work,  particularly  from  a  hard  to 
an  easy  subject,  will  afford  the  same  relief  as  a  short  rest.  Severe  fatigue  comes 
on  with  great  regularity  in  periods  of  the  ancient  languages  and  mathematics, 
while  recuperation  takes  place  during  history,  geography,  and  nature  study. 
The  modern  languages  occupy  a  middle  place;  singing  and  drawing  make  rather 
great  dem.ands  on  those  who  do  weU  in  these  branches.  After  violent  or  pro- 
longed exercise  one  is  less  fit  for  study,  but  after  moderate  exercise  intellectual 
work  seems  to  become  easier.  The  proper  relation  between  physical  and  intel- 
lectual work,  in  order  to  obtain  the  greatest  good  from  each,  is  a  question  which 
should  receive  the  careful  consideration  of  educators. 

Exhaustion  in  Children. — One  of  the  first  ways  in  which  fatigue  shows  itself  is 
in  the  slight  amount  of  force  expended  in  a  movement  and  frequently  a  lessening 
in  the  number  of  movements.  In  extreme  exhaustion  the  ordinary  movements 
are  not  excited  by  ordinary  stimuli,  and  such  as  do  occur  are  slow  and  labored. 
This  may  be  accompanied  by  irritability  and  occasional  jerky  movements  not  con- 
trolled by  circumstances.  Frequently  there  is  manifest  an  asymmetrj'^  of  posture 
and  movement.  The  head  is  held  on  one  side;  the  arms  when  extended  are 
not  horizontal — usually  the  left  one  is  lower;  the  hand  balance  is  weak;  that  is, 

^  Kronecker:  '"Ueber  die  Ermiidung  und  Erholung  der  gest.  Muskeln," 
Leipzig,  1871;  Mosso:  "Fatigue,"  "International  Science  Series,"  Sikorsky: 
"Sur  les  effets  de  la  Lassitude  provoquee  par  les  travaux  inteUectuels  chez  les 
enfants  de  I'age  scolaire;"  Leo  Burgerstein:  "Die  Arbeitskurve  einer  Schul- 
stunde;"  Hugo  Laser:  "Ueber  geistige  Ermiidung  beim  Schulunterrichte." 

117 


Il8  SCHOOL   LIFE    AND    SCOLIOSIS 

when  hands  and  arms  are  held  straight  out  in  front,  the  fingers  and  wrists  are 
not  extended,  and  the  thumb  is  not  on  the  same  plane  as  the  fingers;  this  also  is 
more  marked  in  the  left  hand.  Lack  of  muscular  tone  shows  itself  in  a  "slumped" 
position  either  standing  or  sitting.  The  face  may  be  lengthened  from  relaxation 
of  the  muscles  and  falling  of  the  jaw.  Sighing  and  yawning  are  common 
symptoms.  Speech  is  slow,  and  the  tone  of  the  voice  altered,  and  in  general  there 
are  slowness  and  inaccuracy  of  mental  response. ^ 

School  Furniture. — It  is  obviously  important  to  furnish  school 
children  with  seats  and  desks  which  do  not  favor  improper  attitudes 
in  sitting  and  writing.^  In  1842  Barnard,  of  Hartford,  published  an 
article  on  the  subject,  followed  twenty  years  later  by  Fahrner,^  of 
Zurich,  Myer,*  Cohn,^  Schenk,  Lorenz,^  Schulthess,''  and  Scholder;'' 
and  a  most  practical  study  of  the  matter  was  undertaken  by  the 
Boston  Schoolhouse  Commission.^ 

The  two  things  to  be  prevented  in  school  furniture  are — (a)  the 
prolonged  stretching  of  the  back  muscles  by  the  continued  mainte- 
nance of  flexion  of  the  spine,  and  (b)  the  assumption  of  distorted  and 
twisted  attitudes,  children  with  tired  muscles  tending  to  rest  them  by 
assuming  a  change  of  position.  Furniture  of  bad  design  or  improperly 
fitted  tends  to  favor  both  of  these.  ^°  A  large  number  of  desks  and 
seats  have  been  devised;  it  is  said  that  150  have  been  proposed,  and 
at  least  over  30  have  been  tried.  The  theoretical  requirements  which 
are  by  common  consent  accepted  are  as  follows: 

1.  The  height  of  the  seat  from  the  floor  should  be  such  that  in  sit- 
ting the  feet  rest  on  the  floor.  Too  high  a  seat  produces  pressure 
on  the  back  of  the  thighs;  too  low  a  seat  induces  too  much  flexion  of 
the  lumbar  spine. 

2.  The  slope  of  the  seat  should  be  backward  and  downward  about 
three-eighths  of  an  inch.  The  depth  of  the  seat  should  be  about  two- 
thirds  the  length  of  the  thighs.  The  width  of  the  seat  should  be  that 
of  the  buttocks.  Some  concaving  of  the  seat  is  comfortable,  but  not 
essential. 

3.  The  back  of  the  seat  should  have  a  slope  backward  of  one  in 

twelve  from  the  vertical  line  (Saxon  regulations).     The  more  modern 

^  Warner:  "The  Nervous  System  of  the  Child,"  London,  1900. 
^Scudder:  "Determination   of  the  Muscular  Strength  in  Growing  Girls," 
"Bos.  Med.  and  Surg.  Jour.,"  Nov.  6,  1890. 
^  "Das  Kind  u.  d.  Schultisch,"  1865. 

*  "Die  Mech.  des  Sitzens,"  "Virch.  Arch.  f.  path.  Anat.,"  xxxv,  1867. 
5  "Beitr.  zur  Losung  der  Subsellenfrage,"  Berlin,  1885. 

^Lorenz:  ''Ueber  die  Skol,."  Wien. 
^Schulthess:  "Zeitsch.  f.  orth.  Chir.,"  1892,  i,  i. 
8  "Archiv  fiir  Orth.,"  i,  2. 

*  Boston  Schoolhouse  Commission  Reports  for  1901-5. 
1"  Feiss:  "Cleveland  Med.  Jour.,"  Aug.,  1905. 


WRITING   POSITION 


119 


expression  of  this  is  found  in  two  back  supports,  one  low  down,  one- 
half  to  one  inch  in  front  of  the  back  edge  of  the  seat,  and  a  second 
higher  up,  one  and  one-half  inches  behind  the  back  edge  of  the  seat. 
But  in  a  nearly  balanced  sitting  position  a  relatively  low  back  support 
is  ample  and  the  upper  one  not  required. 

4.  The  height  of  the  desk  should  be  such  that  the  back  edge  allows 
the  forearm  to  rest  on  it  naturally  with  the  elbow  at  the  side.  The 
height  of  this  edge  from  the  edge  of  the  seat  is  known  technically  as 
the  "difference." 

5.  The  slope  of  the  desk  has  been  advocated  at  all  angles  from  o  to 
45  degrees.  The  theoretically  best  slope  for  reading  is  at  least  30 
degrees,  but  this  is  practically 
too  steep  and  books  slide  off, 
and  it  is  not  practicable  for 
writing.  From  10  to  15  de- 
grees is  the  usually  accepted 
inclination.  The  proper  dis- 
tance of  the  eyes  from  the 
desk  is  from  12  to  14  inches. 
The  width  of  the  desk  is  im- 
material, 22  to  24  inches  being 
the  usual  size. 

Writing  Position. — Of  late 
years  there  has  been  a  ten- 
dency to  blame  the  teaching 
of  slanted  handwriting  for 
much  of  the  bad  attitude  and 
the  teaching  of  vertical  writing  was  substituted,  the  patient  sitting 
squarely  in  front  of  the  desk  and  writing  vertically,  with  a  view  of 
avoiding  the  distorted  position  incidental  to  slanted  handwriting. 
Statistics  have  been  reported  in  favor  of  the  vertical  system.  These 
are: 

Percentage  of  Scoliotics 
In  Slanted  Writing  In  Vertical  Writing 

•  Nuremburg 24 

Zurich 32 

Munich 24  15 

Fiirth 65  31 

Wurzburg '. 28  8 


Fig. 


85. — Boston   School   Desk  and  Chair 
■ — (Boston  Schoolhouse  Commission.) 


15 


The  question  is  by  no  means  settled,  Gould,  of  Philadelphia,  having 
called  attention  to  certain  factors  previously  overlooked. 


I20 


SCHOOL    LIFE    AND    SCOLIOSIS 


"  With^  the  head  and  body  erect,  the  paper  straight  before  the  me- 
dian line  of  the  body,  and  the  penholder  held  as  commanded,  no  per- 
son can  or  will  write,  for  the  simple  reason  that  the  writing  and  the 
writing  field  about  the  pen-point  are  hidden  by  the  writing  hand  and 
the  penholder.  Immediately  the  pupil  skews  the  paper,  tilts  the 
head  to  the  left,  and  grasps  the  holder  differently — all  in  order  to 
bring  the  writing  field  and  letters  being  made  into  clear  view,  and 
especially  of  the  right  or  dominant  eye. 


Fig.  86. — The  H.\nd  in  the  Writing  Posture  .\s  Usu.^lly  Ordered,  but  not  Prac- 
tised, Because  to  the  Writer  the  Writing  Field  is  Hidden  by  the  Thumb,  Finger, 
AND  Holder. —  {Gould.) 

A  view  of  the  hand,  as  seen  by  the  writer,  with  the  head  displaced  in  photographing. 


"The  slanted  handwriting  is  due  merely  to  the  fact  that  less  torsion 
or  rotation  of  the  head  to  the  right  is  rendered  necessary,  and  a  slight 
easing  is  secured  by  slanting  the  letters  to  the  right. 

It  may  be  assumed  as  reasonable  (i)  that  bad  air,  fatigue  and 
school  life  under  poor  general  conditions,  (2)  improper  school  furni- 
ture, and  (3)  twisted  writing  positions  favor  bad  attitude,  and  that 
the  more  constantly  they  are  in  operation  the  more  effective  will  be 
their  result  in  producing  bad  attitude.     In  the  same  way  unfavorable 

^  G.  M.  Gould:  "American  Medicine,"  i.\,  14,  562,  1905. 


INCREASES   DURING    SCHOOL  121 

home  conditions  in  the  way  of  bad  food,  overwork,  and  unsanitary 
surroundings  depreciate  muscular  strength  and  favor  bad  attitudes. 

It  is  therefore  likely  on  general  principles  that  unfavorable  school 
conditions  are  a  competent  cause  of  faulty  attitude  (false  scoliosis) 
and  of  slight  grades  of  true  scoliosis,  but  that  they  are  the  cause  of 
moderate  and  severe  scoliosis  is  not,  in  the  writer's  opinion,  likely. 
The  reasons  for  this  view  have  been  expressed  at  the  beginning  of  the 
chapter  on  Occurrence. 

This  view  is  in  accord  with  that  of  the  best  modern  authorities,^ 
but  not  in  accord  with  former  views. ^ 

It  is  therefore  necessary  to  investigate  existing  data  with  regard  to 
the  occurrence  of  scoliosis  in  school  life  to  see  what  evidence  is  to 
be  found  in  them. 

There  are  practically  no  figures  dealing  with  the  question  in 
America  and  it  must  be  remembered  that  figures  from  foreign  sources, 
although  probably  applying  to  our  conditions,  cannot  be  unreserv- 
edly accepted.  It  has  already  been  shown  that  there  may  be  a  great 
variation  in  the  percentage  of  scoliosis  in  the  school  children  of  two 
neighboring  cities  and  between  children  of  different  schools  in  the 
same  city  (see  Occurrence,  page  113). 

Increase  of  Scoliosis  during  School  Life. — When  careful  statistics 
are  taken  among  school  children  they  show  most  often,  but  not  uni- 
formly, a  larger  proportion  of  children  affected  with  scoliosis  in  the 
later  than  in  the  earlier  years  of  school. 

Haglund's  studies^  were  especially  careful  and  show  an  increase 
with  school  age  as  follows: 

Year 6       7       8       9     10     11     12     13     14     15     1599  cases. 

Per  cent,  scoliosis.  11     13     18     16     18     24     22     22     .  .        283  scolioses. 

Gronberg,  from  a  careful  study  of  8350  school  children  in  Finland, 
concluded  that  "the  frequency  of  scoliosis  increases  as  age  increases 
and  as  the  classes  become  higher.  Constancy  of  progression  is  not, 
however,  always  to  be  found." 

His  tables  were  as  follows: 


Year, 

II 

12 

13 

14 

15 

Grammar  schools.  .  . 

12.  2 

15-6 

12.5 

"•3 

16. 1 

Higher  schools 

f    9-4 
\  26.1 

7-3 
32.7 

8.8 
26.9 

9.9 

44-4 

12.4 
40 -3 

Boys. 

1  "Verhdlungen  d.  Deutsch.  Ges.  f.  orth  Chir.,"  1910,  pages  443-514.     Schult- 
hess,  Schanz,  Mayer,  Spitzy,  Bohm,  Muskat,  Lubinus  and  others. 

^  Smith:  "Lat.  Curv.  of  the  Spine  and  Flat-foot,"  New  York,  1911,  page  28. 
^  "Zeitsch.  f.  orth.  Chir.,"  xxvi,  649. 


122 


SCHOOL   LIFE    AND    SCOLIOSIS 


Year, 
Grammar  schools. 

Higher  schools. . . 


21.  2 

f  i6.o 


12 

i8.i 

18.9 


13 
19. 1 

21-5 


14 

23-3 
20.9 


IS 

26.5 

22.3 


16 
21 .9 

24.7 


Girls. 


\48.1     49.0    49.6     59.8     63.2     56.8  J 

The  figures  as  to  the  increase  of  scoliosis  during  school  life  from 
2314  cases  examined  at  Lausanne  are  as  follows:^ 

Age 

8  years. 
9 


Boys 

Girls 

7.8 

per  cent. 

9.7  per  cent 

16.7 

20.1        " 

18.3 

21.8       " 

24.  2 

30.8        " 

27.1 

30.2 

26.3 

37-7 

13 

On  the  other  hand,  certain  observers  have  found  the  contrary. 
Spitzy-  for  ten  years  has  examined  about  too  girls  from  eight  to  six- 
teen years  old  each  year  in  a  large  private  school  for  girls  in  Graz  and 
finds  a  constant  percentage  each  year  of  about  20  per  cent,  of  marked 
defects  of  position,  and  this  percentage  is  not  greater  in  children 
who  have  previously  been  to  school  than  in  those  educated  at  home. 
Hippius^  has  demonstrated  that  severe  scoliosis  is  frequent  in  children 
who  have  never  been  to  school. 

Kirsch*  in  1000  school  children  from  the  lower  classes  and  1000  from 
the  more  advanced  classes  investigated  since  1906  found  that  ''the 
greatest  number  of  all  fixed  scolioses,  which  we  find  in  school,  are 
rachitic  scolioses  from  early  childhood." 

In  3234  girls,  Silfwerskiold  found  percentages  as  follows: 


First  class, 
Second  class. 
Third  class, 
Fourth  class, 
Fifth  class. 


10. 0  per  cent. 

12. 1  " 
12.5  " 
17.0       " 

9.9       " 


Forms  of  Scoliosis  in  School  Children. — "So  far  as  the  forms  of 
scoliosis  which  are  most  frequent  in  children,  they  are  in  a  certain 
way  peculiar  and  vary  from  the  forms  most  frequently  coming  to 
specialists  for  treatment."^ 

Of  these  curves  only  24  per  cent,  were  compound  in  Gronberg's 

series  and  the  remainder  were  simple,  41.9  per  cent,  being  left  total 

*  Combe,  Scholder  and  Weith:  "Jahrb.  der  Schu.  Gesel.  f.  Schulgesundheits 

_e,"  ii,  Jahrg.,  1901,  i,  Tail,  38. 
2  "Verhdl.  d.  Deutsch.  Ges.  f.  orth.  Chir.,"  1910,  page  462. 
'  "Der  kinderarzt  als  Erzieher,"  Berk,  Miinchen. 
^"Verhdl.  d.  Deutsch.  Ges.  f.  orth.  Chir.,"  iqio,  94. 
5  Gronberg:  "Zeitsch  f.  orth.  Chir.,"  xviii.  156. 


CONCLUSION  123 

curves.     In  the  Lausanne  series  48.1  per  cent,  were  left  total  curves 
and  only  8  per  cent,  of  the  whole  were  compound  scoliosis. 

The  conclusion  from  which,  is  that  apparently  if  one  takes  into 
account  all  grades  of  scoliosis,  functional  and  structural  (false  and 
true),  there  is  a  tendency  to  increase  during  school  years,  but  there 
apparently  is  no  good  evidence  that  moderate  and  severe  structural 
scolioses  increase  during  school  life  or  are  directly  caused  by  it. 


CHAPTER  XI 
DIAGNOSIS 

Scoliosis  is  an  affection  in  most  cases  appearing  before  the  tenth 
year;  it  is  not  a  disease  of  the  spine,  but  the  result  of  mechanical- 
forces  acting  upon  a  spine  which  in  other  than  slight  cases  must  be 
assumed  for  some  reason  to  be  abnormally  formed  or  to  possess  less 
than  normal  resistance.  It  is  not,  as  a  rule,  accompanied  by  any 
degree  of  pain.  Stiffness,  if  it  is  present,  is  an  accompaniment  of 
late  cases  and  the  result  of  long-continued  structural  changes. 

In  the  diagnosis  of  scoliosis  the  first  question  that  arises  is  whether 
or  not  scoliosis  is  present.  A  plumb-line  is  held  in  the  line  separat- 
ing the  buttocks,  and  if  all  the  Spinous  processes  lie  under  that  line 
scoliosis  is  not  present.  If  any  number  of  spinous  processes  do 
not  lie  under  the  plumb-line  scoliosis  is  present. 

If  scoliosis  is  present  the  question  is,  is  it  functional  or  structural,, 
and  what  is  the  curve?  The  diagnostic  signs  of  functional  and  struc- 
tural curves  have  been  described  (pages  55,  61,  and  by  aid  of  these 
the  curve  is  classed  as  one  or  the  other  or  as  transitional  (page  57). 
The  ends  of  the  spine  are  connected  by  a  string  and  the  parts  lying 
to  the  right  are  called  right  curves  and  those  to  the  left  are  called 
left  curves. 

If  the  curve  is  functional,  it  is  desirable  if  possible  to  identify  its 
cause  in  a  short  leg,  unequal  vision,  etc. 

If  the  curve  is  structural  it  is  important,  if  possible,  to  assign  it  to 
its  proper  etiological  division. 

Scoliosis  of  Congenital  Origin. — Such  curves  occur  early,  are  gen- 
erally severe,  and  are  best  identified  by  the  .T-ray.  When  accom- 
panied by  gross  defects  in  the  thorax  or  elsewhere  they  are  easily 
recognized. 

Rachitic  Scoliosis. — This  form  occurs  early,  is  generall}^  severe  and 
characterized  by  a  sharp  curve,  and  most  often  found  in  the  lower 
half  of  the  spine.  To  establish  the  diagnosis,  other  signs  of  rickets 
should  be  found.  These  are  the  high  square  head,  the  rosary, 
curved  bones,  enlarged  epiphyses  and  usually  somewhat  retarded 
general  growth.     A  history  of  a  late  first  dentition  suggests  the 

124 


DIAGNOSIS  125 

existence  of  rickets.  Osteomalacia  is  uncommon  and  characterized 
by  severe  general  curvature  of  the  bones. 

Infantile  Paralysis. — This  is  a  motor  paralysis  beginning  with  a 
feverish  attack,  generally  in  summer,  followed  by  loss  of  power  in  one 
or  more  limbs.  The  affected  limbs  are  in  the  severer  cases  cold  and 
wasted  and  reflexes  are  lost.  In  the  severer  cases  of  scoliosis  of  this 
type  the  deformity  becomes  extreme.  There  are  occasional  cases  of 
infantile  paralysis  where  the  attack  is  slight  and  the  loss  of  motion  is 
apparently  recovered  from,  but  where  a  lateral  curve  of  more  or  less 
severity  develops  later  as  a  result  of  the  paralysis  of  some  spinal  mus- 
cles. The  investigation  into  the  history  in  doubtful  cases  becomes  of 
much  importance  and  the  back  should  be  examined  in  every  case  of 
infantile  paralysis  in  any  part  of  the  body. 

Empyema  and  pleurisy  are  recognized  as  the  causes  of  a  severe 
form  of  scoliosis,  especially  when  a  resection  of  the  rib  has  been  per- 
formed in  empyema.  The  curve  is  always  convex  toward  the  unaf- 
fected side  of  the  chest  and  is  dorsal  or  dorsolumbar.  It  is  identified 
by  the  scar  on  the  chest  or  the  auscultation  signs  in  the  thorax  and 
the  history  of  the  case.  Any  other  scar  of  sufficient  size  is  competent 
to  produce  the  same  result. 

Other  evident  causes  of  structural  scoliosis  are  sufficiently  indi- 
cated in  the  table  given  in  the  chapter  on  Etiology. 

Finally,  in  many  cases  no  evident  cause  can  be  found  and  one  is 
obliged  to  assume  that  the  bones  of  the  individual  possess  less  than 
normal  resistance  to  weight  bearing. 

Pathological  Conditions  Accompanied  by  Lateral  Curvature  as  a 
Symptom. — Cases  of  lateral  curvature  accompanied  by  pain,  espe- 
cially if  this  is  exaggerated  by  motion,  should  not  be  given  exercises, 
but  kept  under  careful  observation  until  a  perfectly  definite  diagnosis 
has  been  made.  The  same  applies  to  slight  curves  accompanied  by 
stiffness  of  the  spine.  Doubtful  cases  may  often  be  cleared  up  by  the 
use  of  the  x-xdcy. 

These  painful  conditions  accompanied  by  scoliosis  must  be  care- 
fully separated  from  true  scoliosis.  The  chief  one  of  these  is  Poti's 
disease,  or  tuberculosis  of  the  spine.  The  symptoms  of  this  affection 
are  stiffness  of  gait  and  loss  of  mobility  in  the  spine,  pain  on  motion  or 
jar,  and  spontaneous  pain  in  the  chest  and  abdomen,  elevation  of 
temperature,  and  impairment  of  the  general  condition.  As  the 
disease  progresses,  a  sharp  prominence  backward  of  the  spinous  proc- 
esses occurs  at  some  part  of  the  spine.  Lateral  deviation  of  the 
spine  occurs  in  the  acute  stage  of  practically  all  cases,  but  it  is  a 


126  DIAGNOSIS 

leaning  of  the  body  to  one  side  rather  than  a  true  gradual  curve; 
there  is  no  rotation  of  note,  and  the  lateral  deviation  is  an  index  of 
the  severity  of  the  disease,  disappearing  after  a  period  of  recumbency 
in  bed  and  being  controlled  by  efficient  treatment.  The  danger  of 
mistaking  Pott's  disease  for  scoliosis  lies  in  the  early  cases  before  the 
knuckle,  or  backward  deformity,  has  occurred. 

A  form  of  lateral  deviation  accompanies  arthritis  deformans  of  the 
spine,  which  is  also  known  under  the  names  of  osteoarthritis  of  the 
spine,  spondylitis  deformans,  ankylosis  of  the  spine,  spondylose 
rhizomelique,  Bechterew's  disease,  Steifigkeit  der  Wirbelsaiile,  etc. 
This  is  essentially  an  affection  of  adult  life,  but  not  unknown  in 
children.  The  spine  is  stiff  and  painful,  the  lumbar  convexity  is 
diminished  or  lost,  and  the  curve  a  gradual  one  with  shght  or  no 
rotation. 

The  lateral  curves  accompanying  tumors  of  the  spine,  dislocation 
of  the  vertebrae,  etc.,  would  hardly  be  mistaken  for  real  scoliosis,  the 
usual  signs  of  those  affections  being  present. 


CHAPTER  XII 

PROGNOSIS 

WITHOUT  TREATMENT 

Total  curves  may  remain  as  such  through  life,  probably  increasing 
somewhat;  they  may  change  to  structural  curves;  or  they  may  be 
cured  by  proper  treatment,  but  they  are  not  likely  to  disappear 
spontaneously.  So  long  as  they  remain  purely  functional  curves, 
as  defined  above,  they  will  probably  not  influence  the  general  health 
unfavorably  or  produce  any  unpleasant  result  further  than  slight 
asymmetry.  In  neurasthenic  women  they  are  frequently  accom- 
panied by  backache. 

Structural  curves,  whether  simple  or  compound,  in  young  children 
should  be  regarded  as  serious,  as  almost  sure  to  increase,  and  perhaps 
to  increase  rapidly.  They  will  surely  lead  to  some  deformity,  and 
perhaps  to  grave  deformity.  They  are  likely  to  affect  the  general 
health  and  to  shorten  life  by  inducing  phthisis  and  ill  health.  Adults 
with  severe  scoliosis  are,  as  a  rule,  less  vigorous  than  normal. 

Slight  or  moderate  structural  curves  in  older  children  and  adoles- 
cents which  have  not  progressed  rapidly  through  childhood  are  after 
puberty  likely  to  increase  but  slowly,  if  at  all,  until  late  middle  life, 
when  the  atrophy  of  the  intervertebral  discs  is  likely  to  make  them 
more  evident  and  troublesome.  Severe  structural  scoliosis  at  any 
period  of  life  is  to  be  regarded  as  likely  to  shorten  the  patient's  life 
and  to  induce  ill  health.  The  rapid  increase  of  a  postural  or  struc- 
tural curve  is  a  threatening  symptom  demanding  attention. 

WITH  TREATMENT 

Total  scoliosis  should  be  entirely  and  permanently  cured  by 
adequate  treatment. 

Structural  scoliosis  in  young  children  when  of  moderate  degree 
should  be  practically  cured  by  adequate  and  long-continued  treatment 
but  only  by  that.  If  severe,  it  should  be  much  improved  by  the 
same  means,  the  prognosis  in  both  classes  being  better  in  children 
with  a  long  period  of  growth  ahead  than  in  adolescents. 

127 


128  PROGNOSIS 

Structural  curves  in  older  children  and  adolescents  when  of  ifioder- 
ate  degree  should  be  greatly  improved  by  adequate  and  long-continued 
treatment,  but  as  a  rule  cannot  be  wholly  cured.  Severe  structural 
scoliosis  under  these  conditions  can  be  markedly  improved. 

When  growth  has  been  reached,  only  improvement  and  not  com- 
plete cure  is  to  be  hoped  for  from  treatment  in  true  scoliosis  of  any 
but  the  mildest  grade.  In  adults  with  severe  scoliosis  the  general 
condition  of  the  patient  may  be  greatly  improved  by  an  improved 
position  of  the  spine.  In  late  adult  life  support  of  the  spine  in  the 
best  obtainable  position  is  the  only  outlook  from  treatment,  again 
often  attended  by  improvement  of  the  general  health. 

Scoliosis  due  to  severe  congenital  defects  of  the  vertebra,  scapulae, 
or  thorax,  to  infantile  paralysis,  or  to  empyema  cannot  be  cured  if  a 
curve  of  moderate  or  severe  grade  has  occurred,  but  can  be  improved. 
Rickets  contributes  a  class  of  cases  on  the  whole  resistant  to  treat- 
ment, and  in  severe  cases,  even  in  young  children,  a  complete  cure 
is  probably  not  obtainable.  The  existence  of  organic  heart  disease 
or  phthisis  makes  the  prospect  of  obtaining  much  improvement 
rom  treatment  unfavorable. 


CHAPTER  XIII 
TREATMENT 

The  treatment  of  scoliosis  can  be  most  clearly  considered  if  one 
separates  for  purposes  of  discussion  the  two  types  of  cases  already  de- 
scribed (pages  55-61) — (i)  the  postural  or  functional,  and  (2)  the 
organic  or  structural.  That  such  a  distinction  is  not  always  sharply 
to  be  made,  that  transition  cases  are  to  be  seen,  and  that  many 
therapeutic  measures  are  common  to  both  classes  of  cases,  applies 
here  as  in  most  other  departments  of  medicine  and  surgery  where 
functional  and  organic  conditions  are  separated. 

To  call  both  of  these  varieties  by  one  name,  scoliosis,  leads  to 
confusion  and  contradiction,  to  widely  differing  statements  as  to 
etiology,  and  to  marked  divergence  of  views  with  regard  to  treat- 
ment and  its  results.  If  we  grouped  together  all  sprains  and  joint 
fractures  under  the  term  of  "fractures"  without  regard  to  the 
presence  or  absence  of  bone  injury,  our  classification  and  our  treat- 
ment of  these  injuries  would  become  confused,  contradictory,  and 
unsatisfactory. 

It  is  clearer  to  designate  as  "false"  scoliosis  the  postural  variety, 
and  as  "true"  scoliosis  the  structural  variety,  so  that  in  the  con- 
sideration of  etiology  and  treatment  we  may  not  be  grouping  under 
one  name  two  conditions  essentially  different. 

True  scoliosis  constitutes  our  real  problem,  of  course,  but  in  order 
to  make  that  part  of  the  subject  perfectly  clear,  we  must  first  dis- 
cuss and  remove  from  our  field  the  less  important  question  of  false 
scoliosis. 

THE  TREATMENT  OF  POSTURAL  SCOLIOSIS  (FUNC- 
TIONAL SCOLIOSIS,  FALSE  SCOLIOSIS) 

Regarding  the  condition  as  an  habitual  inability  to  stand  correctly, 

as  a  postural  malposition  without  marked  structural  change,  it  is 

evident  that  the  treatment  should  consist  in  the  substitution  of  a 

,  correct  attitude  for  the  faulty  one.     This  is  obviously  to  be  preceded 

by  eliminating  conditions  unfavorable  to  the  maintenance  of  a  correct 

9  129 


130  TREATMENT 

upright  position.  The  conditions  requiring  investigation  and  pos- 
sible correction  in  every  case  as  a  preliminary  to  beginning  treat- 
ment are — (i)  seats  and  desks  at  school;  (2)  the  manner  of  clothing 
the  child;  (3)  the  condition  of  the  eyes  and  ears;  (4)  the  existence 
of  a  short,  leg;  (5)  overwork  or  too  long  hours,  leading  to  persistent 
fatigue;  (6)  excessive  recent  growth  with  consequent  impairment  of 
resistance.  These  matters  are  also  of  importance  in  structural 
lateral  curvature.  Having  placed  the  patient  under  the  most 
favorable  conditions  obtainable  and  having  corrected  so  far  as 
possible  the  defects  above  mentioned,  the  patient  should  work  on 
the  exercises  to  be  described  for  from  half  an  hour  to  two  hours  a 
day  for  a  period  of  some  weeks,  which  exercises  should  not  be 
pushed  beyond  the  limit  of  fatigue. 

After  a  period  of  vigorous  daily  work  under  the  direct  supervision 
of  the  surgeon,  which  should  generally  be  continued  for  two  or  three 
weeks,  home  work  under  the  direction  of  the  parents  may  be  sub- 
stituted for  it,  with  occasional  supervision  by  the  surgeon  at  longer 
and  longer  intervals.  But  it  is  desirable  that  such  patients  should 
be  under  observation  for  at  least  a  year. 

The  length  of  treatment,  the  period  of  the  exercises,  and  the  extent 
to  which  they  can  be  pushed  will  depend  on  the  vigor  of  the  child, 
as  half-way  measures  are  not  likely  to  be  successful  and  exercises 
done  at  home  under  the  supervision  of  careless  parents  are  less  effi- 
cient than  those  given  by  persons  trained  in  the  art  of  gymnastics. 
The  treatment  lies  within  the  range  of  any  good  teacher  of  gymnastics 
who  will  carry  out  the  instructions  of  the  surgeon.  The  causes  of 
failure  are  to  be  found  in  the  fact  that  such  children  are  generally 
in  poor  muscular  condition  and  are  often  overworked  at  school  or 
under  unfavorable  conditions  at  home,  or  that  the  exercises  are  given 
too  seldom  and  are  not  sufficiently  vigorous. 

If  flexibility  to  one  side  is  limited,  i.e.,  if  the  child  can  bend  further  to 
the  right  than  to  the  left  in  a  left  total  curve,  the  flexibility  of  the  spine 
must  be  made  equal,  preferably  by  means  of  passive  lateral  stretch- 
ing in  the  apparatus,  described  on  page  156,  or  by  means  of  gymnas- 
tic exercises.  Having  restored  the  flexibility  of  the  spine  by  this 
means  or  if  flexibility  to  the  two  sides  is  alike,  a  treatment  differing 
but  little  from  the  "setting-up  drill"  of  the  army  recruit  is  to  be 
instituted.  Exercises  suitable  for  the  treatment  of  postural  cases 
will  be  described  in  connection  with  the  gymnastic  treatment  of 
structural  scoliosis. 


TREATMENT  I3I 

TREATMENT    OF    STRUCTURAL    SCOLIOSIS    (ORGANIC 

SCOLIOSIS,  HABITUAL  SCOLIOSIS,  FIXED 

SCOLIOSIS,  TRUE  SCOLIOSIS) 

The  problem  to  be  met  in  the  treatment  of  lateral  curvature  with 
fixed  bony  changes  is  a  perfectly  definite  one.  A  clear  understanding 
of  the  obstacles  to  be  met  and  of  the  means  at  our  disposal  for  meet- 
ing them  is  essential  to  successful  treatment. 

The  spinal  column  having  curved  to  one  side  has,  in  the  course  of 
time,  become  fixed  in  the  deformed  position.  In  addition  to  the  side 
curve,  a  rotation  or  twist  in  the  length  of  the  column  has  occurred  at 
the  seat  of  the  main  and  compensatory  lateral  curves,  particularly 
evident  in  the  thorax.  As  the  result  of  the  maintenance  of  the 
vicious  position  over  a  long  time,  covering  part  of  the  period  of 
growth,  changes  in  bones,  muscles,  ligaments,  and  intervertebral 
discs  have  occurred.  The  individual  vertebrae  have  become  com- 
pressed on  one  side  and  twisted  by  the  rotation.  The  ligaments  and 
muscles  have  become  adaptively  shortened  on  one  side  and  stretched 
on  the  other,  and  the  intervertebral  discs  to  a  greater  or  less  extent 
have  become  compressed  on  the  concave  side  of  the  curve.  The 
region  of  the  vertebral  column  involved  by  the  curve  has  lost  its 
normal  mobility  and  is  partly  or  wholly  stiff.  There  are  secondary 
changes  in  the  thorax  and  abdomen  and  in  the  contained  organs. 

It  is  obvious  that  in  the  upright  position  gravity  works  to  increase 
the  deformity  by  exerting  pressure  upon  the  concavity  of  the  curves 
already  atrophied  by  an  abnormal  weight  bearing.  Of  the  twenty- 
four  hours  in  each  day  only  some  ten  or  twelve  at  most  are  spent  in 
recumbency.  During  the  remaining  twelve  or  fourteen  hours  the 
vertical  position  is  assumed  and  gravity  is  at  work. 

The  treatment  of  structural  lateral  curvature  presents,  therefore, 
a  much  more  serious  and  much  less  encouraging  problem  than  the 
treatment  of  postural  cases,  and  measures  must  be  vigorous,  ade 
quate  and  stcrgically  sound  to  produce  a  permanently  satisfactory 
result. 

The  causes  of  failure  of  efl&cient  treatment  lie  in  the  unwillingness 
of  the  parents  or  the  patient  to  submit  to  sufl&ciently  long-continued 
and  effective  treatment  to  remedy  a  condition  which,  on  the  sHghtest 
consideration,  can  be  seen_to  be  one  which  is  necessarily  difficult  and 
resistant. 

It  is  evident,  where  the  pathological  changes  have  reached  a 
moderate  degree,  that  considerable  and  continuous  force  would  on 


132  TREATMENT 

general  principles  be  necessary  to  force  the  column  into  a  position 
approximately  normal  and  also  that  on  the  forcing  into  and  holding 
in  such  a  position  depends  our  sole  hope  of  any  considerable  degree  of 
favorable  progress,  progress  necessarily  due  to  the  adaptive  nature 
of  growing  bone — and  to  the  fact  that  in  its  growth  it  will  follow  the 
lines  of  least  resistance.  The  practical  question  is:  how  far  may  we 
depend  on  gymnastic  treatment  alone  to  accomplish  this?  Because 
gymnastic  treatment  is  the  traditional  one  for  scoliosis,  and  is  being 
pursued  in  this  country  to-day  in  the  great  bulk  of  all  cases  which  are 
treated  at  all. 

GYMNASTICS 

Gymnastics  have  a  two-fold  object — first,  to  loosen  up  the  curved 
portion  of  the  spine  to  make  an  improved  position  possible,  and,  sec- 
ond, to  aid  in  retaining  the  improved  position  by  strengthening 
certain  groups  of  muscles.  Most  exercises  tend  in  a  measure  to 
accomplish  both  of  these,  so  that  a  sharp  division  into  mobilizing 
and  retentive  exercises  is  not  possible,  and  one  can  only  point  out 
that  a  certain  exercise  is  especially  valuable  for  one  or  the  other 
purpose. 

It  is  essential  to  define  and  limit  what  place  gymnastics  should 
occupy  in  the  treatment  of  structural  scoliosis.  It  is  obviously  un- 
reasonable to  expect  free  standing  gymnastic  exercises  alone  to 
straighten  marked  or  severe  curves  or  to  change  the  shape  of  dis- 
torted bones.  But  after  the  greatest  possible  improvement  has  been 
secured  in  such  curves  by  more  efi&cient  measures  one  must  look  to 
gymnastics  to  develop  the  muscles  which  will  hold  the  improved 
position  and  make  the  gain  permanent  after  the  corrective  jacket 
has  been  gradually  discontinued.  In  marked  and  severe  structural 
scoliosis,  therefore,  gymnastic  treatment  finds  its  use  as  supplemen- 
tary to  forcible  correction. 

The  purely  gymnastic  treatment  of  severe  structural  scoliosis  is 
to-day  being  largely  pursued  by  two  classes  of  persons.  First,  by 
irresponsible  masseurs  and  medical  gymnasts  who  hold  as  a  tradition 
that  gymnastic  exercises  are  curative  or  at  least  helpful  in  scoliosis, 
and  second,  by  surgeons  who  do  not  believe  in  corsets  or  supports.^ 
The  former  class  serves  only  to  bring  the  legitimate  use  of  gymnastics 
for  scoliosis  into  disrepute;  the  latter  class  use  the  gymnastics  more 
or  less  effectively,  and  take  a  pessimistic  view  of  the  results  to  be 

1  Teschner:  "X.  Y.  Med.  Rec,"  Dec.  6,  1903;  Erich:  "X.  Y.  ISIed.  Jour.," 
Oct.  7,  1899. 


GYMNASTICS 


133 


obtained  in  severe  scoliosis.  Structural  scoliosis  is  a  bone  problem; 
a  glance  at  the  deformed  column  indicates  that,  but  it  has  been  too 
largely  considered  and  treated  as  a  muscle  problem.  Until  recently 
the  treatment  has  been  an  indirect,  intermittent,  and  long-continued 
effort  to  remedy  a  bony  deformity  by  muscular  means.  A  surgeon 
would  be  thought  very  much  behind  the  times  who  to-day  endeav- 
ored to  correct  bony  knock-knee  or 
congenital  olub-foot  by  muscular 
exercise,  yet  many  an  up-to-date 
surgeon  does  not  hesitate  to  advo- 
cate gymnastic  exercise  as  the  sole 
treatment  of  a  bony  deformity 
equally    severe.     The   excuse  for 


Fig.  87. — Patient  with  Left   Dor 
SAL  Curve  in   1900. 


Fig.  88. — Same  Patient  in  1905 
after  Five  Ye.\rs  of  Gymnastic 
Treatment. 


the  use  of  gymnastic  treatment  under  these  conditions  would  be  the 
fact  that  the  results  obtained  by  it  were  so  very  satisfactory  that 
the  practical  outcome  justified  us  in  disregarding  sound  theory. 
But  proof  is  wanting  that  this  is  the  case. 

Gymnastic  treatment  in  apparatus  is,  however,  advocated  as  the 
sole  treatment  for  all  cases  by  such  an  eminent  authority  as  Schul- 
thess,^  and  treatment  by  gymnastics  and  braces  by  an  authority  of 

^  Joachimthal's  Handbuch  d.  orth.  Chir.,  Bd.  iii,  iv  und  v,  page  1035. 


134  TREATMENT 

such  great  weight  as  Lange/  but  neither  of  these  men  has  published, 
nor  apparently  has  claimed,  such  results  as  claimed  and  published 
by  Wullstein,^  Schanz,^  Sever,^  Abbott,^  Lovett^  and  others.  Nor 
can  the  author  find  the  publication  elsewhere  of  results  from  gym- 
nastic treatment  which  are  convincing  as  to  the  efficiency  of  the 
treatment  in  moderate  and  severe  cases.  Still,  one  must  not  pass 
too  lightly  over  the  opinions  of  such  weighty  authorities  as  Schulthess 
and  Lange,  and  must  allow  due  weight  to  them. 

If  one  makes  no  distinction  between  false  and  true  scoliosis,  and 
classes  every  lateral  deviation  of  the  spine  as  scoliosis,  if  he  thus 
groups  false  and  true  scoliosis  together  and  treats  all  cases  by  effect- 
ive gymnastics,  the  proportion  of  successful  results  will  be  large 
because  of  the  predominance  of  the  milder  cases  in  almost  any  group. 
But  if  one  uses  the  gymnastic  treatment  in  a  group  composed  wholly 
of  moderate  and  severe  cases  of  structural  scoliosis,  the  results  will 
be  widely  different  from  those  of  the  first  group.  In  this  failure  to 
separate  the  two  varieties  much  of  the  contradictory  evidence  with 
regard  to  the  results  of  treatment  has  arisen.  Many  well  informed 
surgeons  are  deterred  from  the  use  of  corrective  jackets  by  the  fear 
of  inducing  muscular  atrophy  of  the  back.  But  muscular  atrophy 
of  the  back  is  quickly  recovered  from  and  the  deformity  is  a  grave 
one  demanding  measures  which  strike  at  the  salient  feature — the 
bony  deformity.  The  history  of  the  treatment  of  moderate  and 
severe  structural  scoliosis  as  a  muscle  problem  is  a  history  largely  of 
failure  or  of  extravagant  and  unwarranted  claims. 

Not  only  may  gymnastics  in  moderate  and  severe  structural 
scoliosis  fail  to  do  good,  but  they  frequently  do  serious  harm  for  the 
following  reason :  scoliosis  of  this  grade  soon  results  in  a  stiffening  of 
the  affected  region  of  the  spine.  If  efficient  gymnastics  are  given, 
the  spine  is  speedily  rendered  more  flexible  and  if  it  is  so  rendered  and 
not  supported  at  once,  it  will  sink  into  a  worse  position  than  before 
and  the  curve  will  be  increased.  The  assumption  made  by  the  advo- 
cates of  gymnastics  is  that  the  back  muscles  will  be  so  developed  by 
the  exercises  that  they  will  immediately  hold  the  spine  in  an  im- 
proved position,  but  this  does  not  happen,  and  the  flexibility  in- 

^  Lange  and  Spitzy:  "Handbuch  f.  Khde.,  Leipzig,"  1910,  Bd.  v,  page  140. 

MVullstein:  "Zeitsch.  f.  orth.  Chir.,"  1902,  Bd.  x,  Teil  ii. 

^  Schanz:  "Zeitsch.  f.  orth.  Chir.,"  1908,  Bd.  xxii,  page  57. 

■*  Sever:  "Surgery,  Gynecology  and  Obstetrics,"  September,  1912. 

^Abbott:  "New  York  Med.  Jour.,"  June  24,  1911,  and  April  27,  1912. 

^Lovett:  "Boston  Med.  and  Surg.  Jour.,"  October  31,  1901,  March  17,  1904; 
"Jour.  A.  M.  A.,"  June  23,  1906;  Lovett  and  Sever:  "Jour.  A.  M.  A.,"  September 
2,  1911. 


GYMNASTICS 


135 


creases  much  faster  than  does  the  holding  power  of  the  muscles. 
Much  harm  would  be  avoided  in  the  gymnastic  treatment  of  these 
cases  if  this  practical  fact  were  recognized.^ 

Place  of  Pure  Gymnastic  Treatment. — In  mild  structural  scoliosis 
efficient  gymnastics  should  constitute  the  sole  treatment,  and  may 
be  continued  as  the  sole  treatment  so  long  as  the  improvement  from 
one  exercise  period  persists  until  the  next  one.  If  such  improvement 
is  not  held  between  exercises  it  must  be  assumed — (i)   that  the 


Fig.  89. — Tru^'k  Bending  Ap- 
paratus.— (SchuUhess.) 


Fig.  90.- 


-Shoulder  Pushing  4-pparatus. 

— {SchuUhess.) 


exercises  are  not  good  ones;  (2)  that  they  are  not  properly  carried 
out;  (3)  that  the  amount  of  treatment  is  insufficient,  or  (4)  that 
the  case  is  too  severe  for  purely  gymnastic  treatment.  Progressive 
improvement  must  be  assumed  as  the  criterion  of  efficient  gymnastic 
treatment. 

Ic  is  impossible  to  draw  a  general  line  either  theoretically,  or  in 
practice  at  the  outset  between  cases  of  structural  scoliosis  which  are 
likely  to  be  cured  by  gymnastics  alone  and  those  which  are  not. 

^Chlumsky:  "Verhdlg.  d.  Deutsch.  Ges.  f.  orth.  Chir.,"  1908,  317. 


136 


TREATMENT 


The  line  comes  somewhere  between  the  mild  and  the  moderate  cases 
and  doubtful  cases  should  be  tried  on  the  purely  gymnastic  treat- 
ment and  kept  on  it  only  so  long  as  they  progressively  improve. 
In  other  words  mild  cases  are  generally  suitable  for  gymnastic  treat- 
ment. Cases  of  moderate  grade  with  slight  rotation  and  not  much 
lateral  curve  are  also  to  be  started  on  gymnastic  treatment  for  trial, 
cases  of  moderate  grade  with  marked  rotation  and  curve  are  not 
suitable  for  gymnastic  treatment  alone  and  all  cases  of  severe  scoliosis 
are  unsuited  to  gymnastic  treatment. 


Fig.  91. — Hip-pendulum  and  SHOULDER-RA.ibiNG  Apparatus. — {Schulthess.) 

Scheme  of  Treatment.- — ^(i)  Gymnastics  may  be  given  alone  as  a 
treatment,  or  (2)  in  cases  where  the  patient  becomes  rapidly  flexible 
or  seems  to  require  support  between  exercises,  such  treatment  may  be 
supplemented  by  the  use  of  supporting  jackets,  braces  or  corsets. 
(3)  In  connection  with  gymnastic  treatment  intermittent  passive 
stretching  may  be  useful  in  restoring  flexibility  or  (4)  both  corsets 
and  stretching  may  find  their  use  in  connection  with  gymnastics.  (5) 
Finally  forcible  correction  should  constitute  the  treatment  of  most 
moderate  and  all  severe  cases. 


GYMNASTICS   IN   APPARATUS  137 

The  use  of  braces  and  corsets  alone  cannot  be  considered  a  treat- 
ment for  scoliosis.  To  make  this  matter  plain  the  following  scheme 
presents  the  above  statements  in  the  form  of  a  table: 

/  s   ^  ,.       ,        (  (a)  in  apparatus. 

(i)  Gymnastics  alone  I  j^j  ^.^^^^^  apparatus. 

(2)  Gymnastics  and  corsets. 

(3)  Gymnastics  and  stretching. 

(4)  Gymnastics  and  corsets  and  stretching. 

(5)  Forcible  correction. 

I  (a).  G3minastics  Given  in  Apparatus. — By  means  of  apjparatus 
gymnastic  exercises  can  be  very  much  more  correctly  localized,  and 
the  work  of  loosening  the  spine  and  of  strengthening  the  desired 
muscles  can  go  hand  in  hand.  This  method,  which  is  in  general  use 
in  Europe,  has  never  found  a  foothold  in  this  country  on  account  of 
the  complicated  and  expensive  apparatus. 

The  system  of  apparatus  devised  by  Schulthess  and  its  modifica- 
tions, the  apparatus  of  Zander,  and  the  simpler  apparatus  of  Lange, 
are  the  best  examples  of  the  kind. 

The  precision  of  the  apparatus,  its  adaptation  to  anatomical  needs, 
and  the  principle  of  securing  correction  and  the  development  of 
desired  muscles  at  the  same  time  make  the  system  sound  and  efficient. 

i(b).  Gymnastic  Exercises  Given  Without  Apparatus. — This 
method  of  treatment  is  the  one  in  most  general  use  in  America.  It 
is  open  to  the  objection  that  the  force  exerted  is  not  sufficiently 
localized,  but  is  distributed  over  the  spine. 

Fixation  of, Pelvis. — It  is  essential  that  the  pelvis  should  be  fixed 
during  such  exercises,  as  otherwise  the  pelvis  is  displaced  and  the 
movement  becomes  a  general  and  not  a  local  One.  A  simple  wooden 
apparatus  may  be  constructed  which  holds  the  pelvis  and  does  away 
with  the  necessity  of  holding  the  hips  of  the  patient  between  the 
knees,  which  must  otherwise  be  done.  This  saves  labor  on  the  part  of 
the  person  giving  the  exercises,  and  permits  a  closer  supervision  of  the 
back  than  is  possible  when  part  of  the  attention  must  be  fixed  on 
holding  the  patient  firmly. 

The  apparatus,  which  was  suggested  by  that  of  Bade,^  consists  of  a 
wooden  clamp  made  by  two  flat  boards  set  at  right  angles  to  a  hori- 
zontal board  on  which  they  slide  to  hold  the  sides  of  a  pelvis  of  any 
width.  The  whole  apparatus  moves  up  and  down  on  an  upright 
fastened  to  a  large  round  floor  platform  and  may  be  inclined  at  any 
angle  to  the  horizontal  plane.  The  patient  is  secured  in  place  by 
sliding  in  and  fastening  the  lateral  clamps  at  the  sides  of  the  pelvis, 

^  "Zeitsch.  f.  orth.  Chir.,"  xii,  4,  799. 


138 


TREATMENT 


and  by  securing  the  front  of  the  pelvis  by  a  broad  leather  strap  pass- 
ing from  one  arm  to  the  other.  The  floor  platform  is  so  large  that 
the  apparatus  cannot  upset  (Fig.  94). 

General  Routine  and  Precautions. — It  is  desirable  that  the  back 
should  be  exposed  during  the  exercises  in  order  to  note  the  effect  of 


Fig.  92.— Composite  Photograph  (Two 
Exposures  on  the  Same  Plate)  Show- 
ing THE  Model  Standing  Erect  and 
Bending  to  the  Right  without  Fixa- 
tion OF  the  Pelvis.  The  Movement 
IS  a  General  One. 


Fig.  93. — Composite  Photograph  of 
the  Model  Standing  Erect  and  Bend- 
ing to  the  Right  with  the  Pelvis 
Fixed.  The  Movement  is  Limited  to 
THE  Spine. 


each  one.  •  For  this  purpose  the  patient  should  wear  during  exercises 
a  loose  cotton  dressing  jacket,  fastened  around  the  neck  and  opening 
in  the  back.  This  protects  the  front  of  the  body  but  permits  inspec- 
tion of  the  spine. 

Such  exercises  should  be  simple  and  corrective  in  the  strict  sense; 
that  is  to  say,  an  exercise  which  is  of  use  should  be  seen  to  straighten 


GENERAL  POSTURE   AND   PRECAUTIONS 


139 


the  spine  visibly.  Complicated  exercises  are  dangerous  and  unsur- 
gical.  Work  to  yield  results  must  be  given  by  a  competent  gymnast 
for  a  period  of  from  one  to  three  hours  a  day,  according  to  the  vigor 
of  the  patient,  and  must  be  continued  under  personal  supervision  for 
a  period  of  some  weeks  or  months  to  obtain  satisfactory  results. 
After  this,  exercises  at  home  can  be  substituted  for  part  of  the  per- 
sonal work. 

As  a  preliminary  to  gymnastic  work  the  heart  of  the  patient 
should  have  been,  of  course,  examined.  Afterward  the  weight  should 
be  taken  each  week  as  persistent  loss  of  weight  is  an  indication  for 


Fig.   94. — Apparatus  for  Fixing  the  Pelvis  During  Gymnastic  Exercises. 


moderating  or  discontinuing  temporarily  the  exercises,  providing 
that  the  patient  is  not  being  overworked  at  school,  in  which  case  the 
school  conditions  should  first  be  remedied.  During  menstruation, 
gymnastic  exercises  should  be  suspended.  Persistent  fatigue,  anemia, 
loss  of  appetite,  nervousness,  and  frequent  or  profuse  menstruation 
should  cause  a  careful  investigation  of  the  patient's  environment,  as 
they  may  arise  from  that  or  from  excess  of  gymnastic  work. 

The  following  list  of  gymnastic  exercises,  selected  from  a  large 
number,  may  be  regarded  as  representative  of  the  kind  of  gymnastics 
likely  to  be  of  use  within  the  limits  mentioned  above.     They  will  first 


I40  TREATMENT 

be  described  individually  and  then  analyzed,  and  their  application  to 
different  conditions  will  be  indicated.  The  selection  of  exercises 
must  depend  on  the  requirements  of  each  case.  Simple  develop- 
mental exercises  have  not  been  included  here,  as  a  description  of 
them  can  be  found  in  books  on  gymnastics. 

In  the  explanations  to  be  given  in  connection  with  each  exercise 
the  general  mechanical  features  will  be  discussed,  but  it  must  be 
remembered  that  conditions  observed  in  the  normal  do  not  neces- 
sarily hold  true  in  the  deformed  spine  of  scoliosis,  although  they  form 
the  best  basis  for  analysis.  The  more  nearly  a  spine  approaches  the 
normal,  the  more  likely  is  such  analysis  to  be  correct. 

SYMMETRICAL  EXERCISES 

Exercises  in  the  Standing  Position 

In  all  exercises  given  in  this  position  the  pelvis  should  he  fixed  unless  otherwise 
stated.  It  must  be  remembered  that  exercises  in  this  position  call  into  play  in 
varying  relations  all  muscles  concerned  in  maintaining  the  upright  position,  and 
therefore  cannot  be  as  highly  specialized  as  can  exercises  given  in  the  lying  posi- 
tion. It  must  also  be  remembered  that  the  superincumbent  weight  rests  on  the 
laterally  curved  spine,  and  that  the  curves  are  therefore  not  in  as  favorable  a 
condition  in  such  exercises  as  in  the  lying  position.  On  the  other  hand,  they  are 
useful  because  any  improvement  of  scoliosis  must  be  interpreted  as  meaning 
improvement  in  the  upright  position,  and  all  muscles  concerned  in  that  are 
therefore  of  importance. 

Fundamental  Standing  Position. — The  patient  stands  with  the  knees  extended, 
the  hands  on  the  hips,  the  back  straight,  the  head  erect,  and  the  scapulas  brought 
close  to  each  other.  The  patient  should  not  exaggerate  the  lumbar  curve,  and 
should  press  down  with  both  hands  on  the  hips. 

I.  Trunk  Stretching. — (i)  From  the  fundamental  standing  position  the 
patient  stretches  the  whole  spine  upward.  The  surgeon  holds  his  hand  slighth^ 
above  the  patient's  head  and  urges  her  to  stretch  until  she  can  touch  his  hand 
with  her  head,  keeping  both  heels  on  the  ground.  The  position  of  the  hand  is 
made  higher  as  necessarj'.  (2)  From  the  upward  stretched  position  the  patient 
relaxes  to  the  fundamental  standing  position.  In  count  (i)  the  patient  breathes 
in  and  in  count  (2)  breathes  out  (Fig.  95). 

This  is  a  general  exercise  calling  upon  the  muscles  which  maintain  the  proper 
erect  position,  notably  the  spinal  extensors.  The  elevation  of  the  shoulders 
elevates  and  fixes  the  shoulder-girdle,  giving  a  fixed  point  for  the  pull  of  the  in- 
spiratory muscles,  thus  tending  to  increase  chest  capacity,  and  a  general  stretch- 
ing of  the  spine  is  also  made  easier  by  the  fixed  shoulder-girdle.  The  exercise 
is  applicable  to  any  case  of  scoliosis,  especially  to  postural  curves,  as  a  general 
mobilizing  and  corrective  one. 

II.  Trunk  Bending  Fonvard  with  Trunk  Stretched. — (i)  The  shoulders  are 
raised  as  in  Exercise  I  (i).  (2)  The  patient  bends  her  trunk  forward  to  the  hori- 
zontal position,  the  spine  being  held  straight  and  the  shoulders  raised,  movement 
occurring  only  in  the  hip-joints.     (3)  The  patient  raises  the  trunk  to  the  upright 


SYMMETRICAL    EXERCISES 


141 
(4J  The  patient 


position  with  the  shoulders  still  raised  and  the  spine  straight. 
relaxes  to  the  fundamental  standing  position  (Fig.  96). 

This  combines  the  essentials  of  Exercise  I  with  the  weight  of  the  trunk  thrown 
on  the  extensor  muscles  of  the  back  and  on  the  glutei,  which  must  be  held  con- 
tracted to  maintain  the  forward  bent  position  and  which  must  contract  to  bring 
the  trunk  again  into  the  upright  position.  It  has  the  corrective  effect  of  Exer- 
cise I,  in  addition  to  which  it  is  a  fairly  strong  extensor  spinal  exercise  with  the 
lumbar  curve  flattened.  It  is  a  general  mobilizing  and  corrective  exercise 
which  may  be  safely  used  in  cases  with  a  tendency  to  exaggeration  of  the  lumbar 
curve.  The  patient  inspires  in  (i),  holds  the  breath  during  (2)  and  (3),  and 
breathes  out  in  count  (4). 

The  above  exercises  may  be  modified  and  made  slightly  harder  by  having  the 
patient  place  both  hands  behind  the  neck  with  the  elbows  square  back  as  far 
as  possible.  This  raises  the  center  of  gravity  of  the  trunk  and  therefore  in- 
creases the  leverage  against  the  muscles. 


Fig.  95. 


Fig.  96. 


Fig. 


97- 


III.  Trunk  Twisting. — Position:  Without  pelvic  fixation,  the  feet  parallel  and 
touching,  the  hands  on  the  neck,  the  head  and  spine  erect,  (i)  From  this 
position  the  patient  twists  her  whole  body  as  far  as  possible  to  the  right  or  left, 
the  head  being  turned  as  far  as  possible  in  the  same  direction.  (2)  The  original 
standing  position  is  resumed  (Fig.  97). 

Trunk  rotation  to  the  right  causes  a  left  dorsal  curve  and  vice  versa;  in  addition 
to  this  the  exercise  is  intended  to  be  mobilizing  to  the  whole  body,  especially 
the  hip-joints,  and  greater  trunk  excursion  is  possible  with  the  feet  parallel  than 
with  the  legs  rotated  outward.  The  exercise  is  suitable  for  general  spinal  mobili- 
zation, and  when  given  only  to  one  side  is  a  mild  corrective  exercise  for  lateral 
deviation.  The  effect  of  rotation  upon  the  spine,  especially  in  causing  a  lateral 
curve,  may  be  located  higher  in  the  spine  by  giving  the  rotation  in  the  forward 
bent  position,  and  located  lower  by  giving  it  in  the  hyperextended  position. 


Exercises  Given  in  the  Horizontal  Position 

In  this  group  of  exercises  one  set  of  muscles  may  be  more  readil}'  picked  out 
for  exercise  than  in  the  erect  position.     The  spine  when  prone  is  less  curved  than 


142 


TREATMENT 


in  the  upright  position,  and  is  slacker  and  more  easily  capable  of  side  displace- 
ment. The  fact  that  symmetrical  hyperextensions  are  so  much  used  for  their 
corrective  effect  is  explained  by  their  empirical  value  and  by  anatomical  reasons 
(page  32). 


Lying  on  the  Face. — IV.  Trunk  Raising. — Position:  The  patient  lies  face 
downward  on  a  table  with  the  spine  straight,  the  hands  on  the  hips,  the  scapulae 
approximated  to  each  other,  and  the  legs  secured  to  the  table  by  a  strap  passing 
around  the  table  and  legs  just  above  the  ankles,  or  the  legs  may  be  held  by  the 
hands  of  an  assistant,  (i)  The  patient  inspires  and  raises  the  trunk  from  the 
table,  hyperextending  the  spine  as  far  as  possible,  keeping  the  head  back  and  the 
face  up,  with  the  elbows  still  held  well  back.  (2)  The  patient  breathes  out  and 
sinks  to  the  original  position  (Fig.  98). 

-•^ 
,f  ■■  / 

// 


Fig.  99. 


This  is  an  extension  of  the  spine  from  its  normal  position  to  extreme  hj^per- 
extension  in  which  the  spinal  motion  occurs  largely  below  the  tenth  dorsal 
vertebra,  where  hyperextension  anatomically  takes  place.  The  weight  of  the 
trunk  is  raised  by  action  of  the  back  extensor  muscles  which  are  very  generally 
called  into  play.  It  is  a  general  strengthening  exercise  for  these  muscles,  but 
in  cases  with  marked  increase  of  the  lumbar  curve  it  must  not  be  used  to  increase 
this,  in  such  cases  Exercise  II  being  available.  The  latter  is  probably  a  weaker 
exercise,  because  in  it  the  extensor  muscles  do  not  contract  to  their  fullest  ex- 


SYMMETRICAL   EXERCISES 


143 


Fig.  100. 


Fig.  ioi. 


Fig.  102. 


144 


TREATMENT 


tent.  The  exercise  may  be  made  harder  by  placing  the  hands  behind  the  neck 
and  squaring  the  elbows  back  or  by  extending  the  arms  beside  the  head,  which 
raises  the  center  of  gravity  (Fig.  99). 

The  above  may  be  modified  in  the  following  manner:  The  patient  clasps  his 
hands  behind  his  back  above  the  level  of  the  waist-line,  with  elbows  flexed  and 


ffy 


Fig.  103.  Fig.  104. 

hand  closed  against  the  back,  and,  as  he  hyperextends  his  trunk,  stretches  his 
arms  backward  forcibly,  extending  the  elbows,  and  keeping  the  hands  clasped. 
By  this  modification  the  scapulae  and  shoulder-joints  are  carried  back  and  the 
hyperextension  done  with  an  improved  position  of  the  shoulders.  This  is  par- 
ticularly suited  to  round  shoulders. 


Fig.  ioS- 

This  exercise  may  be  made  stronger  by  the  use  of  dumb-bells  or  a  stafl"  as  indi- 
cated in  Figs.  100,  loi,  102. 

Exercises  Lying  on  the  Face,  the  Trunk  Projecting  over  the  End  of  the  Table.— 
The  legs  rest  on  the  table,  the  surgeon  making  the  ankles  secure  by  means  of 
a  strap  or  by  holding  them.  The  body  above  the  hip-joints  hangs  over  the  table 
end,  head  downward.  The  hands  are  placed  behind  the  neck  with  the  elbows 
squared  back. 


SYMMETRICAL   EXERCISES 


145 


V.  Trunk  Raising  from  Head  Downward  Position. — (r)  The  patient  inspires, 
and  raises  the  trunk  as  far  as  possible  by  hypercxtcnding  the  hip-joints  and  the 
spine.  (2)  During  the  expiration  she  sinks  to  the  primary  position.  The  spine 
should  be  kept  in  the  mid-plane  and  the  head  not  allowed  to  flex  (Fig.  103J. 

This  is  a  spinal  extension  movement  mostly  without  superincumbent  weight, 
beginning  at  forward  flexion  and  ending  in  marked  hyperextension,  calling  the 
extensor  muscles  into  activity  from  a  stretched  to  a  completely  contracted  condi- 
tion. It  thus  combines  the  range  of  motion  in  Exercise  II  with  that  of  Exercise 
IV.  It  is  a  heavier  exercise  than  either.  From  the  start  of  the  exercise  till 
the  horizontal  position  is  reached  the  spinal  extensors  and  glutei  are  the  muscles 
chiefly  active,  as  the  maintenance  of  balance  does  not  require  the  contraction 
of  other  trunk  muscles.  The  exercise  may  be  made  easier  by  placing  the  hands 
on  the  hips.  It  is  of  use  as  a  general  strengthening  exercise  for  the  back  muscles 
in  any  case  where  the  patient  is  strong  enough  to  take  it. 

Exercises  Lying  on  the  Back. — The  patient  lies  on  a  table  or  on  the  floor  with 
the  head,  trunk,  and  legs  straight,  and  the  feet  secured  either  by  a  strap  or  by 
being  held.     The  arms  are  folded  on  the  chest. 


VI.  Tnmk  Raising  to  Sitting  Position. — (i)  The  patient  rises  slowly  to  the 
sittingposition  with  the  spine  stiiif  and  not  allowed  to  flex.  (2)  The  patient  sinks 
to  thejprimarj'  position  with  the  spine  still  stiff,  the  head  touching  the  table 
before  the  back  (Fig.  106). 

The  exercise  is  made  easier  by  placing  the  hands  on  the  hips,  and  harder  by 
placing  the  hands  behind  the  neck  with  the  elbows  squared  back.  The  upright 
position  is  brought  about  by  the  contraction  of  the  abdominal  muscles,  which  aid 
in  maintaining  the  upright  position,  and  require  exercise  in  cases  of  prominent 
abdomen  and  of  increase  of  the  lumbar  physiological  curve  accompanying 
scoliosis  and  round  shoulders. 


Miscellaneous  Symmetrical  Exercises 

VII.  Weight  Carrying  on  the  Head. — A  bag  filled  loosely  with  sand,  weighing 
from  3  to  15  pounds,  is  placed  on  the  top  of  the  patient's  head,  and  she  walks 
slowly  to  and  fro  with  the  arms  preferably  clasped  behind  the  neck  and  the  elbows 
squared  back.  The  exercise  may  be  made  more  diflicult  bj'  having  the  patient 
walk  on  tiptoe.  The  attitude  assumed  should  be  as  erect  as  possible  and  the 
weight  as  heavy  as  can  be  carried  steadih^ 


146 


TREATMENT 


It  is  a  matter  of  common  information  that  the  habitual  carrying  of  baskets 
and  loads  upon  the  head  induces  an  erect  carriage  and  a  straight  spine.  The 
presence  of  weight  upon  the  head  necessitates  holding  the  spine  as  straight  as 
possible  under  the  weight,  as  it  is  thus  most  economically  carried,  and  this  in- 
stinctive adjustment  to  superincumbent  weight  is  depended  on  for  its  corrective 
efifect.  The  exercise  is  suited  to  mild  cases  %vith  noticeable  bad  carriage  and  poor 
balance. 

VIII.  Mirror  Self-corrective  Exercise. — The  patient,  bared  to  the  hips,  faces 
a  mirror  in  front  of  which  hangs  a  plumb-line.  The  patient  then  stands  in  such 
a  position  that  the  plumb-line  cuts  the  middle  of  the  pelvis,  and  by  a  muscular 
effort  brings  the  middle  of  the  thorax  and  the  vertical  line  of  the  face  as  nearly  as 
possible  under  the  plumb-line,  bringing  three  important  landmarks  into  the 
median  line  of  the  body,  thus  securing  an  improved  position.  This  is  held  for  a  few 
seconds  and  then  the  relaxed  position  resumed.  The  exercise  is  repeated  several 
times,  the  improved  position  being  held  longer  each  time. 

The  exercise  is  a  muscle  training  and  is  not  in  any  way  a  mobilizing  exercise, 
but  enables  the  patient  to  associate  a  certain  position  with  a  certain  muscular 
effort,  and  is  of  great  value  in  enabling  patients  to  identify  by  muscular  sense 
the  corrected  position.  The  exercise  requires  but  little  effort  and  may  be  done 
at  home  without  assistance.  It  may  be  modified  in  various  ways  by  adding 
free-arm,  staff,  or  dumb-bell  exercises,  which  change  the  center  of  gravity, 
strengthen  muscles  approximating  the  scapulae,  and  prolong  the  corrected 
attitude. 

ASYMMETRICAL  EXERCISES 

IX.  Hip  Sinking  (Hoffa). — Position:  From  the  fundamental  standing  position 
the  patient  advances  the  foot,  on  the  side  opposite  to  the  convexity  of  the  lateral 
curve,  forward  and  outward  about  two  foot-lengths,  (i)  The  patient  bends  the 
forward  knee,  sinking  the  hip  on  that  side.  (2)  The  patient  resumes  the  primary 
position  (Fig.  107). 


Fig.  107. 


Fig.  108. 


Fig.  109. 


A  passive  side  correction  of  the  lumbar  curve,  due  to  a  lowering  of  the  pelvis 
on  the  side  of  the  advanced  leg  when  the  knee  is  bent.  Suitable  for  lumbar 
curves. 

X.  Self-correction  (Lorenz). — The  patient  assumes  the  fundamental  standing 
position  and  places  the  hand  of  the  side  to  which  the  dorsal  spine  is  convex  upon 


SYMMETRICAL   EXERCISES 


147 


the  side  of  the  thorax  opposite  to  the  greatest  dorsal  curve;  the  other  hand  is 
then  placed  on  the  ilium,  (i)  By  a  side  thrust  of  the  hand  on  the  thorax  the 
patient  corrects  the  dorsal  curve  as  much  as  possible,  maintaining  the  correction 
for  a  few  seconds.  (2)  The  patient  relaxes  to  the  primary  position.  The  exercise 
may  be  modified  by  placing  the  hand  on  the  side  to  which  the  dorsal  spine  is  con- 
cave on  the  top  of  the  head,  as  it  thus  tends  to  raise  a  low  shoulder.  The  rest  of 
the  exercise  is  performed  as  described  (Fig.  loS). 

A  side  thrust  of  the  dorsal  spine  with  pressure  applied  to  the  convexity  of  the 
dorsal  curve  against  resistance  furnished  by  the  other  hand  on  the  ilium  or  the 
head.  Suitable  for  dorsal  scoliosis,  but  not  powerful,  and  useful  as  a  means  of 
stretching;  chiefly  good  because  it  can  be  done  by  the  patient  unaided  at  frequent 
intervals.  Exercises  IX  and  X  may  be  combined  for  a  double  curve  with  one 
element  dorsal  and  the  other  lumbar. 

XI.  Hip  Sinking  from  Stool. — Position:  The  patient  stands  erect  on  a  stool 
on  one  foot  (the  foot  on  the  side  of  the  convexity  of  the  curve),  (i)  The  patient 
lets  the  free  leg  sink  as  much  as  possible,  thus  lowering  the  pelvis  and  hip  on  that 
side.  The  knee  of  the  supporting  leg  must  be  kept  straight.  (2)  The  patient 
resumes  the  original  position  (Fig.  109). 

A  passive  side  stretching  of  the  lumbar  curve  suitable  for  lumbar  scoliosis- 
The  leg  and  pelvis  drag  down  on  the  side  of  the  concavity  of  the  lateral  cuver, 
tending  to  stretch  contracted  structures  and  straighten  the  curve. 


^^^r^:::;;^ 


Fig.  III. 


XII.  Trunk  Hyperextension  tvith  Side  Bending — Lying  on  the  Face. — The 
patient  lies  face  downward  on  a  table  or  on  the  floor  as  described  in  Exercise 
VII.  (i)  The  trunk  is  raised  from  the  table  as  far  as  possible  by  hj'perextending 
the  spine.  (2)  From  this  position  the  trunk  is  bent  to  the  side  toward  which  the 
lumbar  curve  is  convex.  (3)  Position  i  is  resumed.  (4)  The  prone  lying  position 
is  resumed  (Fig.  no). 

This  exercise  is  an  active  lateral  flexion  of  the  spine  in  the  position  of  hyper- 
extension. As  hyperextension  locks  the  dorsal  region  against  side  flexion,  the 
movement  is  almost  wholly  confined  to  the  lumbar  region.  If  there  is  a  right 
dorsal  curve  in  connection  with  a  left  lumbar  curve,  bending  to  the  left,  while 
it  corrects  the  lumbar  curve,  does  not  at  the  same  time  greatly  increase  the  dorsal 
curve,  as  that  part  of  the  spine  is  locked  against  side  bending.  The  exercise  is, 
therefore,  suited  not  only  to  lumbar  curves,  but  especially  to  compound  curves 
in  both  dorsal  and  lumbar  regions. 

XIII.  Draiving  tip  the  Hip — Lying  on  the  Face. — Position:  The  patient  lies 
prone  on  a  table,  holding  the  end  with  both  hands,  the  arms  extended  and  the 
spine  and  legs  in  a  straight  line,  (i)  The  surgeon  grasps  the  ankle  on  the  side  of 
the  lumbar  convexity  and  resists  while  the  patient  draws  the  hip  up  as  far  as  she 
is  able,  knee  the  being  kept  straight.     (2)  Position  i  is  resumed  (Fig.  in). 


148 


TREATMENT 


The  approximation  of  the  side  of  the  pelvis  and  the  thorax  on  the  side  to  which 
the  lumbar  curve  is  convex  is  brought  about  by  an  active  contraction  of  the 
muscles  on  the  convex  side  of  the  lumbar  curve  which  it  is  desirable  to  develop. 
The  amount  of  work  thrown  on  these  is  determined  by  the  amount  of  traction 
made  on  the  ankle.  The  exercise  is  suited  to  cases  of  lumbar  curves  or  to  the 
lumbar  element  of  compound  dorsal  and  lumbar  curves. 


XIV. — Side  Flexion  of  I  he  Trunk  from  the  Side-lying  Position. — Position:  The 
patient  lies  on  a  table  with  the  concavity  of  the  lateral  curve  downward  and  the 
trunk  projecting  over  the  edge  of  the  table  above  the  pelvis,  the  patient  being 
supported  in  this  position,  and  the  ankles  secured  by  means  of  a  strap.  The  spine 
is  held  in  medium  extension,  the  upper  hand  on  the  hip  and  the  lower  hand  on  the 
back  of  the  neck,  (i)  The  trunk  is  bent  laterally  and  upward  as  far  as  possible. 
(2)  The  original  supported  position  is  resumed  (Fig.  112). 


Fig.  113.  Fig.  114. 

In  this  exercise  the  weight  of  the  trunk  is  thrown  on  the  muscles  of  the  convex 
side  of  the  lateral  curve.  The  raising  of  the  trunk  tends  both  to  diminish  a 
curve  existing  near  the  dorsolumbar  junction  and  to  e.xercise  strongly  the  muscles 
which  aid  in  its  correction.  It  is  suited  to  total,  lower  dorsal  and  dorsolumbar 
curves. 


ASYMMETRICAL   EXERCISES 


149 


XV.  Trunk  Bcndiyig  to  Both  Sides  wUh  Hand  Pressure  (Mikulicz). — Position: 
In  the  case  of  a  risht  dorsal  left  lumjjar  curve  the  patient  j)laces  the  right  hand 
on  the  prominence  of  the  ribs  just  under  the  shoulder-blade,  and  the  left  above 
the  ilium  on  the  lumbar  curvature,  (i)  She  then  bends  the  body  slowly  to  the 
right  side,  while  the  right  hand  and  thumb  press  against  the  dorsal  j)rominence. 
(2)  The  upright  position  is  resumed.  (3)  The  patient  bends  to  the  left  and 
backward,  pressing  with  the  left  hand  against  the  lumbar  curve.  (4)  The  up- 
right position  is  resumed  (Fig.  113). 

This  is  a  combined  mild  active  and  passive  correction  for  a  double  curve. 
Opposing  forces  are  applied  to  the  convexities  of  the  curves,  thus  tending  to 
straighten  the  spine,  which  is  at  the  same  time  bent  by  means  of  muscular  action, 
first  to  the  side  of  the  convexity  of  the  dorsal  curve  and  then  to  the  side  of  the 
convexity  of  the  lumbar  curve. 

XVI.  Passive  Head  Side  Bending. — Position:  The  patient  stands  with  the 
hand  on  the  side  of  the  concavity  of  the  lateral  curve  against  the  side  of  the  head 
above  the  ear.  (i)  The  head  is  pushed  as  far  as  possible  to  the  side  that  corrects 
the  curve.     (2)  The  original  position  is  resumed  (Fig.  114). 

A  passive  correction  of  the  cervical  lateral  curve  by  a  side  bend  of  the  upper 
part  of  the  cervical  region  which  tends  to  diminish  the  curve.  Of  use  in  cervical 
and  cervicodorsal  curves,  either  alone  or  existing  in  combination  with  others. 


Fig.  IIS. 


Fig.  116. 


XVII.  Trunk  Raising  with  Asymmetrical  Position  of  Staff — from  Prone  Lying 
Position. — Position:  The  one  described  for  exercises  with  the  patient  lying  on  the 
face  (Exercise  VII)  with  a  stail  grasped  in  both  hands,  the  arms  being  extended 
beside  the  head,  (i)  The  trunk  is  raised  from  the  table  and  the  staff  brought 
over  behind  the  head  obliquely,  the  hand  on  the  side  of  the  convexity  of  the  curve 
being  carried  down  toward  the  feet,  and  the  other  carried  up  over  the  head  until 
the  staff  is  brought  as  nearly  as  possible  into  the  long  axis  of  the  body  and  pressed 
against  the  back.  (2)  By  a  reversal  of  the  movement  the  original  position  is 
resumed  (Fig.   115). 

The  scapula  on  one  side  is  raised,  and  the  position  of  the  staff  tends  to  correct 
an  existing  curve  in  the  dorsal  region.  The  exercise  amounts  to  a  spinal  hyper- 
extension  in  a  corrected  position  of  the  dorsal  spine.  The  exercise  is  suited  to 
total  curves,  to  simple  dorsal  curves,  and  to  compound  dorsal  and  lumbar 
curves. 


i^o 


TREATMENT 


XVIII.  Partial  Suspension  by  One  Arm  "with  Other  Arm  and  Leg  Locked. — 
Position:  The  patient  standing  by  a  ladder  or  under  a  bar  that  can  be  reached 
without  rising  on  the  toes,  grasps  one  rung  of  the  ladder  or  the  bar  with  the  hand 
of  the  side  to  which  the  spine  is  concave.  On  the  opposite  side,  the  convex,  the 
arm  passes  under  the  knee,  the  thigh  being  flexed  at  the  hip,  and  the  shoulder 
and  pelvis  are  thus  approximated,  (i)  The  patient  thus  standing  on  one  leg 
flexes  that  knee  and  allows  the  body-weight  to  come  upon  the  arm.  (2)  The 
original  position  is  resumed  (Fig.  116). 

When  the  arm  is  placed  under  the  knee  the  pelvis  and  shoulder  are  approxi- 
mated on  that  side  and  the  spine  made  convex  to  the  other  side  as  far  as  it  will  go. 
The  structures  on  the  concave  side  are  thus  put  on  the  stretch  and,  by  allowing 
the  body-weight  to  come  on  the  arm  holding  to  the  ladder,  a  further  stretching 
force  is  exerted  on  the  structures  on  the  concave  side.  The  exercise  is  suited 
to  total  and  dorsal  curves. 

Creeping  Exercises  (Klapp). — -In  these  exercises  the  patient  supports  the 
trunk  in  a  horizontal  position  with  the  hands  and  knees  or  feet  on  the  floor.  The 
hands,  knees,  and  toes  should  be  protected  by  leather  pads  which  are  strapped  on. 


Fig.  117. 


Fig.  118. 


XIX.  Symmetrical  Creeping. — -The  hand  and  knee  of  the  right  side  are  placed 
close  together  with  the  hand  to  the  outer  side  of  the  knee,  the  head  is  twisted  with 
the  face  to  the  right,  and  the  trunk  is  rotated  with  the  left  shoulder  upward. 
The  left  arm  is  extended  beyond  the  head  and  the  hand  placed  on  the  floor,  palm 
down  and  fingers  forward,  as  far  forward  as  possible  and  directly  in  front  of  the 
right  knee.  The  left  knee  is  placed  as  far  back  and  as  near  the  median  line  as 
possible;  the  spine  is  strongly  bent  to  the  right.  The  creeping  consists  of  forward 
locomotion  by  a  series  of  reversals  and  regainings  of  the  position  described.  The 
mechanism  of  the  first  reversal  is  as  follows:  the  left  knee  is  drawn  forward  to  the 
inner  side  of  the  left  hand  in  its  original  place  and  position,  the  right  arm  is 
extended  above  the  head,  and  the  hand  placed  as  far  in  front  of  the  left  knee  as 
possible  with  the  palm  down  and  fingers  front.  At  the  same  time  the  spine  is 
rotated  to  bring  the  right  shoulder  high,  the  face  is  twisted  to  the  left,  and  the 
spine  flexed  to  the  left.  The  restoration  to  the  first  position  is  secured  by  again 
moving  the  back  knee  (right)  and  the  back  hand  (left)   (Fig.  117). 

This  is  a  general  muscle  strengthening  and  spine-mobilizing  exercise.  It  is 
comparatively  mild  and  may  be  continued  for  long  periods  of  from  twenty  to 
forty  minutes.  Symmetrical  creeping  is  properly  that  which  is  done  rapidly, 
and  is  of  most  value  in  restoration  of  flexibility. 

A  modification  is  made  by  creeping  slowly,  holding  each  position  and  putting 
force  into  the  stretching,  usually  holding  the  position  longest  which  stretches  the 
concavity  of  the  most  marked  curve  (Fig.  118).  Another  modification  is  creep-, 
ing  in  place,  which  differs  from  the  above  in  that  the  patient  does  not  attempt 
locomotion.  The  position  is  somewhat  as  above  except  that  the  fingers  of 
both  hands  are  placed  on  the  floor  opposite  to  the  side  to  which  the  face  looks. 
The  trunk  is  rotated  till  the  side  with  the  forward  arm  is  uppermost,  and  the  arm 
is  carried  directly  over  the  head,  while  the  under  arm  is  flexed  at  the  elbow  which 


JACKETS    AND   BRACES 


151 


points  to  the  side  toward  which  the  face  is  turned;  the  posterior  knee  is  straight- 
ened, and  the  foot  only  of  that  limb  touches  the  floor.  The  patient  then  endeav- 
ors to  look  upward  beneath  the  forward  reaching  arm.  This  is  best  employed 
as  an  asymmetrical  exercise  to  correct  the  dorsal  convexity  and  stretch  the 
side  of  the  concavity  (Fig.  119). 

XX.  Creeping  Sidewise. — There  is  a  third  asymmetrical  variation  in  "creeping 
sidewise"  toward  the  side  showing  the  concavity  of  the  curve  to  be  corrected,  for 
example,  in  a  left  total  curve.  The  patient  creeps  sidewise  to  the  right.  The  left 
hand  and  knee  are  placed'under  the  trunk,  and  as  far  as  possible  to  the  right  of  the 
right  hand  and  knee.  The  right  hand  and  knee  are  then  advanced  to  the  right 
and  the  above  is  repeated.     The  face  should  look  to  the  left  (Fig.  120). 

This  is  a  corrective  exercise  similar  to  other  forms  of  creeping,  and  may  also 
be  used  for  dorsal  curves  as  well  as  for  those  of  the  total  type. 


Fig.  119. 


Fig.  120, 


XXI.  Creeping  with  Arm  Flinging  Upward. — Another  kind  of  creeping  in  which 
the  upper  part  of  the  spine  is  especially  concerned  is  the  creeping  with  arm 
flinging  upward.  The  starting  position  is  the  same  as  for  ordinary  creeping — 
hands  and  knees  on  floor,  hand  and  knee  of  one  side  touching,  hand  and  knee  of 
opposite  side  stretched  far  apart.  The  patient  brings  up  the  backward  knee  until 
it  touches  the  forward  hand,  then  raises  the  opposite  hand  from  the  floor,  and  with 
elbow  straight  swings  the  whole  arm  upward  so  that  the  impetus  of  the  swing 
twists  the  dorsal  spine  and  causes  the  whole  trunk  to  turn.  At  the  same  time  the 
patient  turns  her  head  and  looks  up  at  the  hand  that  is  raised.  This  stretched 
position  is  held  for  a  second,  then  the  arm  is  swung  downward  again  and  the  hand 
placed  as  far  forward  on  the  floor  as  possible. 

(2)  JACKETS,  BEACES  AND  CORSETS 

Braces  and  corsets  of  themselves  have  no  place  in  the  corrective 
treatment  of  lateral  curvature,  and  are  only  to  be  regarded  as  a 
means  of  retaining  the  gain  secured  by  other  methods.  They  must 
be  regarded  as  having  in  themselves  little  corrective  value,  for  such 
apparatus  applied  to  the  spine  not  previously  loosened  up  by  treat- 
ment is  not  able  to  secure  any  considerable  correction  by  pressure 
on  the  spine  because  the  base  for  the  leverage  to  be  obtained  from 
the  pelvis  must  consist  in  a  pressure  obtained  from  the  space  be- 
tween the  crest  of  the  ilium  and  the  top  of  the  trochanter.  Direct 
pressure  on  the  crest  of  the  ilium  is  not  tolerated,  and  pressure  on 
the  trochanter  interferes  with  walking  and  sitting.     It  is  manifestly 


152 


TREATMENT 


impracticable  from  this  small  space  to  obtain  a  hold  which  will 
exercise  a  sufficient  side  thrust  on  the  thorax  to  be  corrective.  The 
current  practice  of  the  instrument-makers  of  fitting  corsets  and 


Fig.  121. — On  the  Left  is  a  Plaster  Torso  Made  from  a  Corrective  Jacket.  On 
THE  Right  is  the  Same  Torso  Made  More  Symmetrical  for  the  Application  of  a  Re- 
movable Jacket. 

braces  to  such  patients  and  allowing  the  parents  to  hope  for  any 
considerable  benefit  is  therefore  to  be  condemned. 

The  complicated  braces  in  former  use  have  been  largely  displaced  by 


Fig.  122. — Brace  for  Scoliosis,  Back. 
— (£.  H.  Bradford.) 


Fig.  123. — Brace  for  Scoliosis, 
Front. — (£.  H.  Bradford.) 


the  jacket  or  corset.     They  may  be  found  described  in  the  references.  ^ 

The  corset  used  in  Germany  is  shown  in  the  illustration  (Fig.  126). 

1  Hoffa:  "Lehrb.  d.  orth.  Chir.,"  fourth  ed.,  1905,  page  429;  Redard:  "Chir- 
urgie  Orthopedique/'  Paris,  1S92,  page  382;  Bradford  andLovett:  "Orth.  Surg.," 
first  ed.,  i890,page  168. 


JACKETS,  BRACES  AND  CORSETS 


153 


Fig.  124. — Brace  for  Scoliosis, 
Back. — (Z.  B.  Adams.) 


Fig.  125. — Brace  for  Scoliosis, 
Front. — (Z.  B.  Adams.) 


Fig.  126. — Corset  for  Scoliosis  Strength-       Fig.  127. — Bracefor  a  Case  of  Right  Dorsal 
ENED  BY  Steel. — (Dolega.)  Scoliosis,  Applied. —  {C.  W .  Keene.^ 


154  TREATMENT 

The  braces  of  Bradford,  Adams,  and  Keene  are  representative  of 
the  best  types  of  modern  retention  braces,  but  in  the  writer's  ex- 
perience better  correction  is  maintained  by  removable  jackets  than 
by  braces. 

Under  the  conditions  specified  the  choice  between  a  removable 
jacket,  a  corset,  or  a  brace,  will  be  determined  by  the  facility  of 
the  surgeon  with  each. 

(3)  PASSIVE  STRETCHING  OF  THE  SPINE 

It  is  at  times  desirable  to  increase  flexibility  of  the  spine  more 
rapidly  than  can  be  done  by  free  standing  gymnastics  alone  and 
stretching  of  the  contracted  structures  is  in  all  cases  of  structural 
scoliosis  except  the  mildest  more  easily  to  be  obtained  by  intermit- 
tent passive  stretching  in  apparatus  than  by  gymnastics  alone. 
The  following  considerations  bear  on  the  use  of  stretching  force  as 
applied  to  the  spine  whether  in  intermittent  stretching  or  in  forcible 
correction. 

The  least  economical  use  of  force  in  straightening,  for  example,  a 
bent  stick  is  to  pull  the  two  ends  away  from  each  other,  i.e.,  to 
straighten  it  by  a  pull  in  its  length.  The  most  economical  use  of 
force  is  to  take  it  by  the  two  ends  and  press  the  point  of  greatest 
convexity  against  some  resisting  point  which  shall  push  it  straight. 

Again,  if  one  wishes  to  secure  the  greatest  side  displacement  in  a 
flexible  rod,  such  displacement  is  more  easily  secured  when  the  rod  is 
not  stretched  in  its  length.  If  a  rubber  tube,  for  example,  is  fastened 
to  a  table  by  two  pins,  one  at  each  end  and  is  not  put  on  the  stretch, 
the  middle  of  it  can  easily  be  pulled  an  inch  to  one  side  by  the  fore- 
finger. If,  however,  it  is  pinned  to  the  table  by  two  pins  separated 
enough  to  hold  it  on  the  stretch,  it  will  require  much  more  force  to 
displace  it  one  inch  to  the  side.  The  same  is  true  of  a  strip  of  sponge 
rubber  or  a  piece  of  rattan. 

To  be  sure  that  this  theoretical  consideration  applied  to  the  human  spine  the 
following  experiment  was  made  at  the  Harvard  Medical  School  by  the  courtesy 
of  the  late  Prof.  Thomas  D  wight. 

Head  suspension  is  a  passive  stretching  of  the  spine,  corrective  through  its 
entire  length,  tending  to  improve  both  rotation  and  side  deviation  at  the  curves, 
but  exercising  still  more  force  upon  the  more  nearly  normal  parts  of  the  spine 
because  the  latter  are  more  movable.  Suspension  by  the  arms  is  less  eflScient, 
and  does  not  affect  the  cervical  vertebrae  as  does  head  suspension. 

A  young  male  cadaver  was  laid  on  the  face,  and  straps  passed  around  the  body 
at  the  level  of  the  right  shoulder  and  the  right  hip.  These  straps  were  then 
fastened  to  the  left  side  of  the  table,  holding  the  shoulder  and  hip  against  pres- 


STRETCHING    OF   THE    SPINE 


155 


sure  from  the  left.  A  strap  was  then  passed  around  the  left  side  of  the  thorax 
and  by  means  of  a  spring  balance  pulled  to  the  right.  The  side  deviation  of  the 
spine  was  then  measured  at  four  levels,  the  measurements  being  taken  from  a 
base-line  connecting  the  cervical  spine  and  the  sacrum.  The  measurements  were 
all  made  from  pins  driven  into  the  spinous  processes.  Three  experiments  were 
made  with  a  side  pull  of  25  pounds  and  the  results  were  recorded. 

A  Sayre  head-sling  was  then  put 
around  the  head  of  the  cadaver  still 
lying  on  the  face,  and  a  traction  force 
of  75  pounds  was  made  in  the  length 
of  the  spine,  the  feet  of  the  cadaver 
being  fastened  to  the  table.  While 
the  traction  on  the  head  was  thus  in 
force  the  same  side  puU  of  25  pounds 
was  made  as  before  and  the  results 
noted.  Two  experiments  of  this  sort 
were  made.  It  was  found  that  the 
spine  without  traction  was  displaced 
to  the  side  nearly  twice  as  far  by 
a  definite  side  pull  as  by  the  same 
amount  of  side  pull  when  traction 
was  being  made. 

A  confirmatory  experiment  was 
made  on  a  healthy  boy  of  fifteen, 
using  75  pounds  of  head  traction  and 
15  pounds  of  side  pull.  The  result 
was  the  same. 

The  conclusion  is  that  extension  of 
the  spine  by  an  upward  pull  on  the 
head  is  a  corrective  force  in  the  nor- 
mal spine,  but  that  much  more  force 
is  required  to  accomplish  a  certain 
amount  of  side  correction  than  is  the 
case  if  the  force  is  applied  from  the 
side. 

The  other  conclusion  is  that  to 
secure  the  maximum  of  side  dis- 
placement from  a  given  amount  of 
side  pressure  the  spine  must  be  slack 
and  not  stretched  in  its  length.  fig.  isS.—Head  Traction. 


(4)  PASSIVE  STRETCHING  BY  SUSPENSION 

The  patient  stands  or  sits  erect,  and  the  head  is  pulled  vertically  upward  by 
means  of  a  Sayre  head-sling,  which  embraces  the  chin  and  occiput.  Traction 
should  be  made  by  a  compound  pulley,  and  the  patient  or  the  surgeon  may  hold 
the  rope.  Suspension  is  mildest — (i)  when  the  feet  are  not  made  to  leave  the 
floor;  next  in  grade  comes  (2)  the  position  of  tiptoe  induced  by  the  traction,  and 
(3)  a  greater  pull  is  secured  by  lifting  the  whole  body  until  the  feet  swing  free. 


156 


TREATMENT 


In  this  case  the  traction  force  equals  the  body-weight.  The  maximum  traction 
can  be  secured  (4)  by  strapping  the  thighs  down  to  a  seat  on  which  the  patient 
sits.  An  upward  pull  greater  than  the  body-weight  can  now  be  exerted  on  the 
head  (Fig.  128). 

Apparatus  for  the  purpose  has  been  devised,  and  is  known  as  the 
Weigel-Hoffa  frame,  in  which  the  patient  is  suspended  by  the  head, 


Fig.  129. — Stretching    Board    with   Loops,    Ready   for   Applic.'\.tion. — {"Jour.    Am. 

Med.  Assn.") 


Fig.   130. — Stretching  Board  with  Loops  Applied  to  a  Patient.     Reverse  of  Fig.  129. 
— {"Jour.  Am.  Med.  Assn.") 


while  pads  are  run  in  from  the  sides  of  the  frame,  making  lateral  pres- 
sure on  the  trunk  in  various  directions. 

Correction  of  the  lateral  curve  of  the  spine  is,  however,  to  be 
obtained  more  economically  by  having  the  patient  lie  prone,  and  the 


FORCIBLE    CORRECTION  1 57 

corrective  force  should  be  divided  into  two  elements,  the  force  to 
correct  the  rotation  and  the  force  to  correct  the  side  deviation.  A 
simple  apparatus  for  this  is  as  follows  (Fig.  129) : 

The  patient  lies  face  downward,  with  the  knees  flexed,  on  a  board  three  feet 
wide  by  four  feet  long.  Assuming  the  case  to  be  of  a  right  dorsal  curve,  a  broad 
canvas  strap  is  passed  around  the  left  thorax,  over  and  under  the  patient,  and 
fastened  to  a  cleat  on  the  right  side  of  the  board.  This  furnishes  a  point  of 
pressure  to  the  left  against  the  upper  thorax  at  the  level  of  the  axilla.  A  broad 
canvas  strap  is  then  passed  around  tHe  pelvis  of  the  patient  above  and  below,  and 
is  fastened  to  a  cleat  at  the  right  side  of  the  board.  This  furnishes  a  point  of 
pressure  to  the  left  at  the  level  of  the  pelvis.  A  broad  canvas  strap  is  then  passed 
around  the  thorax  at  the  level  of  the  greatest  point  of  curve;  it  passes  above  and 
below  the  thorax  and  its  upper  end  is  fastened  to  a  cleat  at  the  left  side  of  the 
board  (Fig.  130).  Its  lower  end  is  fastened  by  means  of  a  string  into  a  compound 
pulley  attached  to  a  cleat  at  the  left  side  of  the  board.  By  means  of  this  pulley 
any  reasonable  degree  of  force  may  be  exerted  against  the  right  side  of  the  thorax, 
pulling  it  to  the  left,  and  at  the  same  time  that  it  pulls,  it  tends  to  reduce  the 
rotation  from  the  fact  that  its  upper  end  is  fastened  and  its  lower  end  moving 
toward  the  pulley. 

(S)   FORCIBLE  CORRECTION 

In  marked  moderate  and  in  severe  structural  lateral  curvature  no 
means  of  treatment  is  in  the  opinion  of  the  author  so  efficient  as  con- 
tinuous stretching  by  means  of  plaster  jackets  applied  under  force. 
This  method  is  spoken  of  as  "forcible  correction."  Such  jackets  are 
applied  with  the  purpose  of  stretching  the  contracted  structures  and 
of  inducing  an  improvement  in  the  curve. 

From  the  time  of  the  elder  Sayre,  who  advocated  for  scoliosis  the 
application  of  plaster  jackets  applied  in  mild  suspension,  in  several 
papers  between  1875  and  1885,  there  had  been  sporadic  attempts  at 
the  use  of  continuous  mild  corrective  force  in  the  treatment  of  scolio- 
sis. Dating  from  the  work  in  1896  of  Calot^  who  advocated  at  that 
time  the  use  of  forcible  correction  in  the  treatment  of  Pott's  disease, 
the  attempts  became  more  forcible.  Schanz- published  in  1900  an 
account  of  an  efficient  technic  in  suspension,  and  reported  results 
in  1902.  In  1901  the  author  reported  results  and  described  a  technic 
where  the  patient  lay  on  the  face  during  the  application,  ^  and  there 
were  other  papers  written  at  about  this  time,  but  the  great  impetus  to 
the  treatment  by  forcible  correction  came  from  Wullstein,^  who  read 

^  Calot:  "France  Med.,"  1896,  52;  12th  Int.  Med.  Congress,  Moscow,  1897. 
^Schanz:  "Munch,  med.  Woch.,"  1900,  Bd.  xlvi. 

^Lovett:  "Trans.  Amer.  Orth.  Asso.,"  1901,  vol.  xiv;  "Boston  Med.  and 
Surg.  Jour.,"  October  31,  1901. 

^  "Zeitsch.  f.  orth.  Chir.,"  1902,  Bd.  x. 


158  TREATMENT 

a  paper  at  the  International  Medical  Congress  in  Paris  in  1900,  and 
who  published  his  experiments,  method,  and  results  in  1902.  He 
showed  experimentally  that  bony  scoliosis  could  be  produced  in 
young  dogs  and  by  the  use  of  plaster-of -Paris  jackets  applied  to  sco- 
liotic patients  in  an  improved  position,  induced  by  the  use  of  traction 
and  lateral  pressure,  both  of  high  degree,  he  secured  results  that  were 
better  than  any  previously  reported.  The  work  attracted  much 
attention,  and  markedly  modified  the  whole  point  of  view  with 
regard  to  "forcible  correction,"  which  began  to  gather  a  body  of 
adherents  whose  number  has  steadily  increased. 

The  object  of  the  corrective  jacket  being  to  force  the  spine  into 
the  best  obtainable  position,  and  in  that  position  to  apply  a  retentive 
plaster  jacket,  it  becomes  pertinent  to  inquire  in  what  position  and 
b}'  what  technic  the  best  corrected  position  may  be  obtained. 

Five  positions  are  to  be  considered;  these  are  with  the  patient 
suspended  and  lying  on  the  face,  side  or  back,  and  in  the  rotated 
position  advocated  by  Forbes.^ 

Application  in  Suspension. — Sayre's  jackets  were  applied  with  the 
patient  suspended  by  the  head  with  the  heels  lifted  from  the  ground, 
and  he  claimed  for  them  nothing  more  than  support  in  an  improved 
position.  The  jackets  were  removable,  and  exercises  were  done 
daily.  The  treatment  was  too  mild  to  be  effective,  and  although 
extensively  used  was  not  followed  by  very  successful  results. 

Wullstein's  method  was  also  a  suspension  method,  but  he  used  250 
pounds  of  traction,  and  to  secure  this,  the  patient  was  strapped  by 
the  thighs  to  a  revolving  and  tilting  stool  and  lateral  pressure  was 
secured  by  pads  running  in  from  an  upright  frame  on  horizontal  rods. 
These  pads  were  incorporated  in  the  jacket.  Much  greater  force  was 
used  than  ever  before,  and  although  unpleasant  symptoms  from  pres- 
sure arose  at  times,  the  results  were  so  good  that  the  method  was 
extensively  used,  and  is  still  in  vogue  on  the  continent  of  Europe. 

The  method  of  Schanz  is  simpler  and  in  connection  with  the  after- 
treatment  highly  efficient  if  one  may  judge  by  the  admirable  results 
obtained,  but  at  the  same  time  an  amount  of  traction  is  used  which 
is  objectionable  if  the  same  results  can  be  obtained  by  other  means. 
The  patient  stands  and  the  ankles  are  fastened  by  anklets  to  rings 
bolted  to  the  floor.  By  means  of  a  Sayre  head  sling  extension  is  pro- 
duced by  means  of  a  windlass  to  the  point  of  the  patient's  tolerance. 
A  plaster  jacket  including  the  shoulders  is  then  applied  and  as  it  is 
hardening  the  surgeon  passes  his  arms  around  the  pelvis  of  the  patient 

1  "N.  Y.  Med.  Journ.,"  July  6,  1912. 


FORCIBLE    CORRECTION 


159 


and  with  his  shoulder  protected  by  a  pad,  presses  against  the  rotated 
and  curved  portion  of  the  spine.  The  after-treatment  followed  by 
Schanz  consists  in  prolonging  recumbency  in  a  corrected  posterior 
plaster-of-Paris  shell  with  head  traction.  The  patient  is  turned  once 
a  day  onto  the  face  to  have  the  back  massaged,  but  no  exercises  are 


Fig.   131. — Patient    with    Plaster    Jacket    Applied    in    Wullstein's    Apparatus. 

— (Wullstein.) 


given  at  this  period.  After  months  of  recumbency  a  corset  and 
headpiece  are  applied  and  the  patient  allowed  gradually  to  sit  up. 
At  a  later  period  exercises  are  begun. 

Advantages  and  Disadvantages  of  Suspension  Positions. — The  use 
of  strong  traction  in  the  length  of  the  spine  tends  to  straighten  the 
lateral  curves  and  to  diminish  the  rotation,  but  without  added  lateral 


i6o 


TREATMENT 


pressure  sufficient  correction  is  not  obtained.  Moreover,  traction 
in  the  length  of  the  spine  makes  it  resistant  to  side  displacement 
from  lateral  pressure,  as  a  stretched  spine  is  less  easily  displaced  to 
the  side  than  a  slack  spine.  Wullstein  found  that  he  must  diminish 
the  traction  on  the  head  to  get  the  best  results  from  side  pressure. 
But  the  upright  position  is  the  one  in  which  the  patient  will  wear 
the  jacket;  the  technic  of  application  is  in  this  position  the  simplest, 
access  to  the  shoulders  and  neck  is  easy,  and  the  lower  part  of  the 


Fig.  132. — Appliance  for  Lateral  Suspension  and  the  Application  of  Retentive 
■Casts. — (Rich,  "Jour.  Amer.  Med.  Assoc,"  Dec,  1911.) 

jacket  can  be  accurately  fitted  to  the  pelvis.  Under  these  conditions 
a  close-fitting  and  presentable  jacket  can  be  most  easily  applied  by 
this  method. 

Application  of  Corrective  Jackets  Lying  on  the  Side. — A  method 
has  been  devised  by  Rich^  in  which  the  patient  lies  on  the  side  and 
is  suspended  by  a  sling  passing  around  the  convexity  of  the  lateral 
curve,  other  slings  hold  the  head  and  pelvis,  and  rotation  is  con- 
trolled by  an  oblique  pull.     The  jacket  is  applied  as  a  figure  eight 

1  "Jour.  Am.  Med.  Assn.,"  Dec.  30,  191 1. 


FORCIBLE    COraiECTION 


i6i 


bandage,  with  the  upper  turn  embracing  the  root  of  the  neck,  the 
lower  turn  the  pelvis,  and  the  crossing  coming  over  the  convexity  of 
the  spinal  curve. 

Advantages  and  Disadvantages  of  the  Side  Lying  Position.— Tht 
chief  advantages  of  this  posi- 
tion consist  in  the  fact  that 
the  patient  is  suspended, 
and  thus  all  parts  are  easily 
accessible.  The  figure-of- 
eight  bandage  fulfils  admir- 
ably the  mechanical  require- 


FiG.  133. — Anterior  View  of  Pa- 
tient Showing  Freedom  of  Chest 
OVER  Areas  of  Coistcavity. — {Rich, 
"Jour.  Amer.  Med.  Assoc,  Dec, 
1911.) 


Fig.    134. — Patient    Thirteen    Years     Old. 
Curvature  Due  to  Rickets;  Never  Treated. 


ments,  and  the  body  weight  is  utilized  to   straighten   the    spinal 
curves.     The  method  is  not  applicable,  except  to  children. 

Application  of  Corrective  Jacket  in  the  Prone  Position. — When 
corrective  jackets  are  applied  to  the  patients  prone,  it  is  desirable  to 
flex  the  legs,  as  this  diminishes  the  physiological  curves  of  the  spine 
and  simplifies  the  problem.  With  a  patient  thus  lying  prone,  the 
spine  is  open  to  inspection  and  relaxed.  In  this  improved  position 
the  jacket  is  applied. 


l62 


TREATMENT 


A  simple  application  of  this  method  is  to  be  found  by  having  the  patient  lie 
prone  in  a  rectangular  gas-pipe  frame  on  two  straps  of  webbing  running  from 
end  to  end,  cross  straps  supporting  the  pelvis  and  shoulders.  By  means  of  web- 
bing straps  attached  to  the  side  of  the  frame,  in  a  right  dorsal  curve,  one  going 
around  the  left  side  of  the  pelvis  and  another  around  the  left  upper  thorax,  while  a 
third  pulls  on  the  right  side  of  the  thorax  against  these  as  points  of  resistance, 
great  force  may  be  exerted  on  the  spine,  much  more  force  than  can  be  safely  used. 
With  the  patient  lying  prone  on  the  webbing  strips  which  are  padded,  the  pelvic 
and  axillary  straps  are  adjusted  to  the  proper  tension  and  tied  around  the  side 
of  the  frame.     A  heavy  pad  of  felt  is  then  applied  over  the  rotated  and  curved 


Fig.  13  s. — Patient  Lying  in  Correc- 
xrvE  Frame,  Showing  the  Improvement 
Gained  by  the  Horizontal  Position. 
Photograph  taken  from   above. 
Patient  same  as  in  Fig.  134. 


Fig.  136. — Patient  in  CoRRECTrvE 
Frame  with  Side  Pressure  Applied 
BY  Strap. 

Showing  additional  correction  to  that 
in  Fig.  135. 


portion  and  a  webbing  strap  attached  to  the  side  of  the  frame  and  tied  at  one 
end.  This  strap  is  then  passed  over  the  rotation,  under  the  patient  and  back 
to  the  frame.  By  pulling  on  this  end  of  the  strap  (the  upper  end  of  which 
has  already  been  tied)  the  curved  portion  of  the  spine  is  pulled  to  the  side  and 
the  rotation  acted  on  by  the  twisting  action  of  the  strap.  When  sufficient 
tension  has  been  obtained  the  end  of  the  strap  is  fastened  to  the  frame.  The 
jacket  is  then  applied  with  the  side  webbing  straps  in  place,  the  bandages  being 
worked  around  the  straps.  When  the  plaster  is  sufficiently  hard  these  side 
straps  are  cut  off  where  they  emerge  from  the  jacket  and  a  finishing  bandage 
applied.  The  patient  then  stands  up;  the  longitudinal  straps  are  pulled  out, 
the  jacket  is  cut  out  under  the  arms  and  by  plaster  bandages  the  jacket  should  be 


PLASTER   JACKETS 


163 


y 


extended  to  include  the  shoulders,  which  is  iilways  desirable,  but  not  always 
tolerated. 

Mechanics  and  Technic  of  Application  of  Jackets  in  Prone 
Position. — -When  it  comes  to  the  apphcation  of  corrective  force 
it  must  be  remembered  that  there  are  two  elements  in  the  deformity, 
namely,  side  deviation  and  rotation.  A  single  correcting  force 
would  therefore  have  to  be  oblique,  e.g.,  in  a  right  dorsal  curve  for- 
ward and  to  the  left.  But  for  practical  purposes  it  is  desirable  to 
use  two  forces,  one  forward  and  one  laterally  toward  the  spine, 
thus  dealing  separately  with  the 
two  elements  of  the  deformity. 
To  attempt  to  correct  the  side 
curve  by  lateral  pressure  without 
attacking  the  rotation  is  likely  to 
result  in  increase  of  the  rotation 
by  pressure  on  the  already  flat- 
tened shafts  of  the  ribs. 

That  this  is  not  new  may  be 
appreciated  by  a  quotation  from 
Schreger^  in  1810:  "Der  seitliche 
Druck  auf  die  Rippen  biege  diese 
an  den  ohnehin  schon  mehr  spitzen 
Wikelh  noch  mehr  spitzig  zu." 
That  plaster  jackets  may  cause 
increase  of  the  rib  angles  is 
demonstrated  by  Hiissey.^  The 
same  point,  that  plaster  jackets 
may  increase  the  bony  rotation 
apparent  in  the  back,  has  been 
alluded  to  by  Schulthess  and 
Vulpius.^ 

It  may,  therefore,  be  stated  that  attempts  to  diminish  the  lateral 
curve,  by  pure  lateral  pressure,  not  carefully  antagonized,  will  result, 
in  fixed  curves,  in  an  increase  of  the  rotation. 

The  solution  hes  in  dealing  separately  with  the  rotation  and  with 
the  lateral  deviation.  Having  corrected  the  lateral  deviation  first, 
this  correction  is  held,  as  will  be  described,  while  the  rotation  is 
corrected  or  vice  versa.  In  this  way  one  element  is  not  improved  at 
the  expense  of  the  other. 

1  Fischer,  quoted  by  Hiissey. 

2  Hussey:  "Zeitsch.  f.  orth.  Chir.,"  viii,  2,  235. 

^  Vulpius:  "Volkmann's  Samml.  klin.  Vort.,"  276. 


Fig.  137. — On  the  Left  is  a  Diagram 
Showing  a  Right  Dorsal  Left  Lumbar 
Curve. 

In  the  middle  diagram  the  curve  is 
shown  straightened;  on  the  right  the 
curve  has  been  pushed  over  to  the  left 
unchanged. 


164 


TREATMENT 


Technic  of  Application. — The  patient  should  preferably  be  stretched  once  or 
twice  daily  for  two  or  three  days  preliminary  to  the  correction,  but  this  is  not 
essential.  Anesthesia  is  never  necessary,  as  all  endurable  correction  may  be 
obtained  without  much  pain.  A  seamless  undervest  is  put  on  and  the  iliac 
crests  padded  with  heavy  felt;  a  pad  should  also  be  placed  over  the  sacrum. 
Under  the  side  straps  heavy  felt  or  cotton  pads  are  required. 

The  correction  is  pushed  to  the  point  of  causing  mild  discomfort,  and  difficulty 
in  breathing  is  a  sign  of  too  much  correction.  The  amount  to  be  obtained  in  any 
case  is  better  decided  by  the  patient's  sensations  than  by  any  theoretical  stand- 


r 


Fig.  138.- 


-Patient  of  Whom  Radiograms  were  Taken  before  Treatment. 
1906.) — {"Am.  Jour.  Med.  Assn.") 


(January, 


ard.  The  danger  lies  on  the  side  of  obtaining  too  much  rather  than  too  little 
correction,  for  the  jacket  will  be  much  more  uncomfortable  when  the  erect  posi- 
tion is  assumed. 

After  correction  the  patient  should  remain  in  a  hospital  under  close  obser- 
vation for  at  least  twenty-four  hours.  Some  shock  is  not  infrequently  experi- 
enced and  in  a  case  of  the  writer's  very  serious  collapse  and  cyanosis  followed 
the  correction  of  a  severe  curve  due  to  infantile  paralysis  in  a  child  of  si.s:.  W uU- 
stein  has  recorded  the  occurrence  of  somewhat  serious  symptoms  following 
correction. 

Advantages  and  Disadvantages  of  the  Prone  Position. — The  spine 
in  this  position  is  slack  and  easily  displaced  to  the  side  and  twisted, 


APPLICATION   OF   JACKETS  165 

and  the  back  is  in  view  of  the  surgeon  during  the  application,  enab- 
ling him  to  see  just  what  correction  is  being  accomplished.  But 
jackets  applied  by  this  method  are  clumsy,  as  it  is  difhcult  to  fit  the 
pelvis  accurately,  especially  if  the  thighs  are  flexed,  access  to  the 
chest  and  shoulders  is  not  easy,  and  the  front  of  the  jacket  is  con- 
cealed from   the  surgeon's  view. 

Application  of  Jackets  in  the  Rotated  Position  {Forbes  Method).^ 
■ — The  method  assumes  that  it  is  probable  that  the  deformity  arises 
in  some  cases  from  the  rotation  of  the  vertebral  bodies  and  that  an 
artificial  scoliosis  in  the  other  direction  should  be  induced  to  counter- 
act it.  But  such  an  assumption  does  not  seem  to  be  borne  out  by 
what  we  know  of  the  occurrence  of  scoliosis.  Nor  does  untwisting 
one  part  of  the  rotation  seem  likely  to  be  of  much  use  when  such  a 
complicated  set  of  rotations  exist  as  one  finds  in  compound  structural 
scoHosis.  The  justification  of  such  a  method  would  have  to  be 
found  in  the  fact  that  it  produced  correction.  In  this  matter  one 
may  rely  on  the  verdict  of  the  Scoliosis  Committee  of  the  American 
Orthopedic  Association  who  examined  six  cases  to  be  treated  by 
this  method  in  October,  1914,  and  again  in  April,  1915,  after  six 
months  of  treatment.  Their  report  is  as  follows:^  "They  were  all  in 
fairly  good  condition  but  in  two  cases  collapse  seemed  imminent 
after  the  jacket  had  been  removed  and  the  patients  kept  standing  for 
inspection.  Not  only  had  overcorrection  not  been  secured  in  any 
case,  but  in  none  was  there  marked  diminution  in  any  elements  of  the 
deformity.  .  .  .  The  treatment  of  all  the  cases  in  this  group  seemed 
to  have  been  carried  out  with  great  care  and  perseverance,  but 
the  Committee  feel  justified  in  considering  the  results  as  distinctly 
discouraging." 

In  view  of  what  has  been  said  the  treatment  is  not  in  the  writer's 
opinion  to  be  recommended  until  further  evidence  of  its  practical 
value  is  brought  forward. 

Application  of  Jackets  Lying  on  the  Back  with  the  Spine  Flexed 
{Abbotfs  MeJiod).^- — The  patient  lies  on  the  back  with  the  legs  flexed 
on  the  trunk,  the  back  rests  on  a  hammock  about  a  yard  long  and 
fifteen  inches  wide  cut  obliquely  across  one  end.     This  hammock  is 

1  Forbes:  "N.  Y.  Med.  Journ.,"  July  6,  1912;  Maidermot:  "American  Journ.  of 
Orth.  Surg.,  Feb.,  1913;  Forbes:  "Surgery,  Gyn.  and  Obst.,"  April,  1914;  Adams: 
"American  Journ.  of  Orth.  Surg.,"  July,  1914. 

2  "American  Journ.  of  Orth.  Surg.,"  July,  1915,  page  6. 

^  Abbott :  "Simple,  Rapid  and  Complete  Reduction  of  Deformity  in  Fixed  Lateral 
Curvature  of  the  Spine,"  "N.  Y.  Med.  Journ.,"  June  24,  191 1.  "Forcible  Correc- 
tion of  Lateral  Curvature  of  the  Spine,  a  Simple  and  Rapid  jMethod  of  Obtaining 
Complete  Correction,"  "N.  Y.  Med.  Journ.,"  Apr.  27,  1912. 


l66  TREATMENT 

fastened  at  each  end  to  a  steel  rod  by  which  it  is  loosened  or  tightened. 
It  is  held  in  place  by  being  slung  between  the  ends  of  a  gas-pipe  frame 
about  five  and  one-half  feet  long  and  two  feet  wide.  This  frame  rests 
on  four  gas-pipe  legs  and  has  a  bar  running  lengthwise  in  the  middle, 
about  two  feet  above  the  main  level  of  the  frame  to  which  the  legs  are 
slung,  and  nearer  the  ground  are  side  bars  to  which  straps  may  be 
attached.  The  patient  is  padded  with  thick  felt  and  laid  on  the  back 
on  the  frame  and  the  legs  are  flexed  and  fastened  to  the  upper  rod, 
the  shorter  side  of  the  hammock  resting  against  the  bulging  ribs,  a 
crosspiece  of  webbing  supports  the  neck.  Cross  straps  are  now  ap- 
plied around  the  body  to  pull  in  the  desired  direction,  one  in  the 
axilla  of  the  low  shoulder  carried  obliquely  across  the  frame  to  the 
upper  corner,  another  around  the  pelvis  pulling  across  to  the  same 
side  of  the  frame  as  the  axillary  strap,  another  strap  is  passed  over  the 
most  convex  part  of  the  dorsal  lateral  curve  to  the  opposite  side  of  the 
frame  to  pull  on  the  dorsal  curve  and  a  fourth  strap,  wider  than  the 
others,  may  be  used  to  pass  from  the  side  of  the  frame  running  over 
the  anterior  protruding  ribs  and  hanging  down.  To  this  weights 
may  be  attached  to  influence  the  rotation.  A  large  oval  felt  pad  is 
placed  over  the  back  of  the  thorax  on  the  side  where  the  ribs  are 
depressed.     The  straps  are  tightened  and  the  jacket  applied. 

In  trimming  the  jacket  it  is  left  long  behind  at  the  bottom  to  main- 
tain flexion  of  the  spine;  at  the  top  it  is  left  high  under  the  arm  which 
has  been  elevated,  but  is  cut  away  on  that  side  in  front;  beneath  the 
other  arm  it  is  trimmed  low  but  left  high  in  front  to  hold  that 
shoulder  back.  A  large  window  is  cut  in  the  back  over  the  concave 
side,  reaching  well  around  to  the  side  so  that  the  spine  may  swing 
not  only  back  but  to  the  side,  on  the  opposite  side  in  front  a  window 
is  cut  to  allow  the  depressed  ribs  on  that  side  to  bulge  anteriorly. 
After  the  jacket  has  been  worn  for  a  short  time  pads  of  felt  are  in- 
serted in  front  to  push  the  ribs  back  through  the  window  cut  behind 
and  sometimes  pads  are  also  to  be  used  over  the  convexity  at  the 
back. 

Choice  of  Method. — In  choosing  between  these  methods  it  is  prob- 
able that  most  of  them  are  eiJ&cient  and  that  the  especial  technic 
employed  is  probably  less  important  than  the  skill  of  the  surgeon  and 
his  experience  with  the  particular  method  employed,  the  amount  of 
force  used  and  the  efficiency  of  the  after-treatment.  But  one  fact 
must  be  borne  in  mind,  there  are  two  kinds  of  correction,  one  a  real 
correction  of  the  spine  of  which  the  x-ray  is  the  only  criterion,  and 
second,  an  apparent  correction  in  which  the  thorax  is  rotated  on  the 


DISCUSSION   OF    METHODS  167 

spine  with  great  improvement  and  perhaps  even  overcorrection  of  the 
body  outlines  but  in  which  an  x-ra,y  shows  the  lateral  curve  to  be  largely 
or  wholly  unchanged.  In  other  words  it  is  easier  to  rotate  the  thorax 
on  the  spine  than  to  change  the  curve  of  the  spine  itself  and  herein  lies 
the  weakness  of  the  method  advocated  by  Abbott  in  which  the  thorax 
is  most  easily  to  be  rotated  on  the  spine — apparent  correction,  that 
is,  correction  of  body  outline,  has  figured  in  many  reported  cases  in 
which  the  x-ray  has  not  been  shown  and  where  progress  has  been 
judged  only  by  photographs.  An  instance  of  this  is  given  in  the 
figures  (Figs.  155  and  156).  The  prone  lying  and  suspension 
methods  do  not  render  the  thorax  so  easily  movable  on  the  spine 
and  it  is  probable  that  force  expended  in  correction  is  more  nearly 
spent  on  the  spine  itself.  But  the  whole  question  as  to  choice  of 
methods  is  sub  judice. 

As  to  the  overcorrection  of  the  curve  in  marked  or  severe  struc- 
tural scoliosis,  such  a  claim  must  be  substantiated  by  very  weighty 
evidence  for  such  an  overcorrection  would  be  contrary  to  all  that 
we  know  of  bone  pathology,  and  a  claim  of  such  overcorrection  is  not 
lightly  to  be  accepted. 

A  committee  of  the  American  Orthopedic  Association  appointed 
in  1913,  in  June,  1915,  reported  as  follows:  They  had  sent  out  a 
questionnaire  to  fifty  members  of  the  association  in  which  the 
following  two  questions  were  asked: 

"i.  Have  you  personally  had  cases  of  undoubted  structural  scoliosis  in  which 
unquestionable  overcorrection  was  obtained? 

"2.  Have  you  succeeded  in  bringing  about  a  definite  cure  of  undoubted 
structural  scoliosis? 

"But  one  man  in  fifty  has  claimed  without  qualification  to  have  brought  about 
a  definite  cure  of  undoubted  structural  scoliosis.  Although  he  was  immediately 
requested  to  furnish  the  evidence  and  although  he  had  volunteered  to  do  so, 
the  committee  has  not  received  it.  The  committee  therefore  concludes  that  of 
the  fifty  men  who  have  replied  to  the  postal  card  questionnaire,  none  are  in 
possession  of  material  evidence  with  which  to  give  an  affirmative  answer  to 
questions  i  and  2 

"Note. — Since  the  completion  of  the  report  the  one  definite  and  unqualified 
claim  of  cure  in  undoubtedly  structural  scoliosis  has  been  retracted  by  letter  to 
the  committee."^ 

The  two  most  careful  studies  of  the  Abbott  method,  apart  from 
Abbott's  own  articles,  are  by  Lance  of  Paris  and  Kleinberg  of  New 
York.     The  conclusions  of  Lance^  were  as  follows: 

^"Am.  Journ   of  Orth.  Surg.,"  July,  1915,  page  18. 

^ Lance:  Le  Traitement  des  Scoliosis  graves  par  la  Methode  d' Abbott.  Paris, 
1914. 


1 68  TREATMENT 

"In  the  cases  where  there  is  no  marked  bony  lesion  one  can  always  accomplish 
correction  and  hypercorrection  of  the  lateral  deviation.  In  the  cases  where 
there  are  bony  lesions  in  a  single  curve  without  compensatory  curves,  or  with  a 
compensatory  curve  not  presenting  deformed  vertebrae,  one  observes  this — that 
the  principal  curvature  diminishes  in  all  the  vertebrae  which  are  not  deformed, 
ar^d  there  remains  a  little  curve  of  two,  three  or  four  vertebrae  in  height,  composed 
of  cuneiform  and  rhomboid  vertebrae,  and  above  and  below  at  rather  a  brusque 
angle  are  formed  very  extensive  compensatory  curves.  We  have  never  been 
able  to  obtain  more.  Abbott  says  that  he  has  obtained  complete  redressment 
and  hypercorrection  of  scoliosis  with  vertebral  deformity,  but  he  has  never  pro- 
duced radiographs  demonstrative  of  the  fact In  the  very  severe  cases, 

where  the  vertebral  deformities  exist  not  onlj'  in  the  upper  curve  but  on  one  or 
two  of  the  compensatory  curves  the  action  is  very  limited,  and  one  will  only 
obtain  a  result  very  slightly  marked,  and  which  will  have  very  slight  chance 
of  being  maintained." 

Kleinberg,^  from  an  analysis  of  60  cases,  reaches  the  following 
conclusions: 

"As  might  have  been  expected,  it  was  found  that  the  deformity  even  in  its 
mildest  form,  did  not  yield  rapidly  to  the  Abbott  treatment,  and  that  it  took 
months  to  effect  any  real  change.  Of  the  60  cases,  18.  .  .  gave  up  treatment, 
8  were  not  improved  at  all,  and  34  were  definitely  made  better  in  external 
appearance,  with  or  without  a  corresponding  change  in  the  spine  itself.  Of 
this  latter  number  6  cases  relapsed.  This  method,  therefore,  is  applicable 
to  the  milder  degrees  of  rigid  scoliosis,  most  of  which  the  writer  has  seen  improved, 
though  he  has  not  yet  seen  any  case,  no  matter  how  mild,  cured,  that  is,  trans- 
formed into  one  with  a  prefectly  symmetrical  back." 

Taking  all  this  evidence  which  is  wholly  in  accord  with  the  writer's 
own  experience  one  must  fairly  conclude  that  the  situation  is  much 
what  it  was  before.  The  method  of  Abbott  is  no  cure  all,  and  his 
claims  have  apparently  not  been  substantiated  by  others.  One  has 
only  to  realize  what  Abbott's  claim  was  to  recognize  its  character. 
It  was  as  follows:^  ''In  a  previous  article  on  this  subject^  the  state- 
ment was  made  that  fixed  lateral  curvature  of  the  spine  yielded 
to  treatment  as  easily  as  bowlegs  or  club-feet.  Further  experience 
has  led  me  to  believe  that  this  deformity  yields  more  readily  than 
either  of  the  others." 

The  method  of  Abbott  may  be  a  little  more  or  a  little  less  effective 
than  the  suspended  or  prone  lying  positions,  the  scoliosis  Committee 
of  the  American  Orthopedic  Association  in  their  admirable  report 
said:     ''It  seems  probable  that  greater  degrees  of  correction  may  be 

'  "American  Journ.  of  Orth.  Surg.,"  June,  1914. 
^"N.  Y.  Med.  Journ.,"  Apr.  27,  1912. 
^  "N.  Y.  Med.  Journ.,"  June  24,  1911. 


DISCUSSION    OF   METHODS 


169 


obtained  with  the  flexed  position  of  the  spine  than  with  the  extended 
position  of  the  spine." 

Personally  the  author  would  regard  the  fully  flexed  position  as  the 
one  in  which  it  was  easiest  to  secure  an  improvement  in  body  outline 
for  the  spine  thus  seems  to  be  more  flexible  to  manipulation  and 
it  may  also  be  the  position  in  which  the  greatest  real  correction  of  the 
spine  is  to  be  obtained.  But  although  one  hesitates  to  generalize 
from  a  single  instance,  certain  doubt  was  thrown  on  the  latter  point 


Fig.   139. — Patient  Shown  in  Fig.  138  after  Wearing  Corrective  Jacket  for  over 
A  Year.     (March,  1907.) 

by  an  observation  of  the  author's  in  which  x-rays  were  taken  of  a 
boy  with  scoliosis  in  the  Abbott  position  and  in  the  prone  lying  posi- 
tion with  the  same  amount  of  lateral  pull.  The  prone  position 
showed  slightly  more  spinal  correction  but  such  an  observation 
would  have  to  be  confirmed  to  be  convincing.  For  the  present 
we  need  accurate  data  in  the  way  of  x-rays,  photographs  as  explained 
are  misleading  and  impressions  of  little  value;  meanwhile  the  ques- 
tion must  remain  subjudice. 

The  choice  therefore  must  be  left  to  the  individual  surgeon,  the 


lyo 


TREATMENT 


method  by  rotation  (Forbes)  has  not  apparently  yielded  results  as 
good  as  have  the  other  methods,  the  method  of  side  lying  (Rich) 
has^not  been  generally  adopted,  and  the  surgeon  must  choose  accord- 
ing to  his  preference  between  head  suspension,  prone  lying  and  the 
flexed  position  lying  on  the  back. 

Treatment  Subsequent  to  Application  of  Jacket. — Starting  from  the 
application  of  the  corrective  jacket  two  methods  of  treatment  are 


Fig.  140. — Radiogram  of  a  Patient  Seventeen  Years  Old  (Fig.  138)  Lying  on  the 
Back,  before  the  Application  of  Jacket.  (January,  1906). — ("Jour.  Am.  Med. 
Assn.") 

available;  (i)  the  original  jacket  may  be  left  on  or  (2)  after  one  or 
more  corrective  jackets  have  been  applied  a  removable  jacket  or 
corset  or  brace  may  be  used. 

(i)  Permanent  Corrective  Jackets. — When  the  jacket  is  hardened,  it- 
is  left  solid  over  the  parts  that  are  made  prominent  by  the  rotation 


PERMANENT   CORRECTIVE   JACKETS 


171 


behind  and  in  front,  that  is,  in  a  right  dorsal  curve  the  right  back 
and  left  front  are  not  touched,  but  large  windows  are  cut  over  the 
depressed  side  of  the  chest  behind  and  the  corresponding  portion 
diagonally  opposite  in  front,  so  that  in  a  right  dorsal  curve  the  left 
side  would  be  cut  out  behind  and  the  right  side  in  front.  This  makes 
it  possible  for  the  depressed  parts  of  the  chest  to  be  expanded  by 
respiration,  while  the  prominent  parts  are  compressed.     Pads  of  felt 


Fig.  141. — Radiogram  of  Same  Patient  as  Shown  in  Fig.  138,  Taken  after  the 
Application  of  a  Plaster  Jacket  through  Windows  Cut  in  Front  and  Back  of 
Jacket.     (January,  1906.) — {"Jour.  Amer.  Med.  Assn.") 

are  now  inserted  between  the  prominent  part  of  the  chest  behind  and 
the  jacket,  and  in  the  corresponding  region  in  the  front,  thus  making 
the  jacket  more  corrective,  and  thicker  pads  are  substituted  each 
week  without  changing  the  jacket,  these  being  drawn  through  with- 
out difficulty  by  means  of  a  bandage.  In  this  way,  a  continual 
diagonal  side-pressure  is  kept  up  on  the  curved  portion  of  the  spine 
and  is  steadily  increased.     Whe'n  these  pads  have  become  so  thick 


172 


TREATMENT 


that  the  jacket  is  pushed  away  from  the  patient  and  no  longer  fits 
it  will  be  found  that  it  is  advisable  to  apply  a  new  jacket,  to  cut  it 
out  in  the  same  way  and  to  begin  on  the  progressive  padding.  The 
use  of  such  a  permanent  jacket  may  be  continued  as  long  as  it  seems 
possible  to  gain  further  correction,  being  changed  at  intervals,  and 
at  the  end  of  this  time  a  removable  jacket  is  substituted  for  the 
permanent  one  and  gymnastic  treatment  is  begun.     The  removable 


Fig.   145 


-Fenestrated  Jacket  for   Making  Side   Pressure 
— (Ansel  G.   Cook.) 


3V  Strap. 


jacket  is  then  gradually  discontinued  while  the  patient's  muscular 
condition  is  being  improved  by  gymnastic  exercises. 

(2)  Removable  Jackets. — The  treatment,  by  removable  jackets,  is 
best  started  by  the  application  of  a  forcible  jacket  either  in  recum- 
bency or  suspension.  This  may  be  followed  by  a  second  forcible 
jacket  at  an  interval  of  a  week  or  so,  if  it  seems  advisable.  For  the 
construction  of  the  removable  jacket,  the  patient  is  suspended 
and  a  plaster  jacket  is  applied  which  is  immediately  cut  off  to  serve 
as  a  mold,  and  a  forcible  jacket  is  best  applied  to  be  worn  while  the 
removable  apparatus  is  being  made.     The  jacket  which  is  to  serve  as 


CORRECTION   OF    TORSO 


173 


a  mold  is  then  bound  together  and  filled  with  plaster  of  Paris  and 
water,  a  torso  thus  being  obtained.  This  torso  is  then  remodeled  by 
cutting  off  on  the  prominent  side  and  building  up  on  the  other  side, 
until  it  has  become  decidedly  more  symmetrical  than  the  patient. 
It  is  also  sawed  in  halves  at  the  waist 
and  set  apart  about  an  inch  in  order  to 
secure  continued  extension  of  the  trunk. 

On  this  corrected  torso  a  plaster  jacket 
is  applied  which  is  to  be  the  removable 
jacket  worn  by  the  patient.  This  re- 
movable jacket  should  be  supplied  with 
shoulder  pads,  to  hold  the  shoulders  back 
in  position,  and  should  open  down  the 
front,  being  supplied  with  buckles  and 
straps  or  lacings.  It  is  generally  advis- 
able to  slash  such  jackets  over  the  iliac 
crests  in  order  to  prevent  chafing.  The 
addition  of  5  per  cent.  Portland  cement 
to  the  plaster  with  which  the  jacket  is 
made  gives  greater  strength  and  dura- 
bility. This  jacket  is  to  be  worn  by  the 
patient  night  and  day  and  to  be  removed 
only  for  the  exercise  period,  which 
should  consist  of  one  hour  or  more 
daily,  the  exercises  being  of  the  type 
mentioned  above.  When  the  jacket  is 
applied,  it  is  sprung  open  and  slipped 
on  the  patient,  who  then  lies  on  the 
back,  and  the  arms  and  legs  are  pulled 
on  to  extend  the  spine.  It  is  then 
buckled  tightly  in  place  before  the 
patient  stands  up.  Such  jackets  may 
be  made  more  effective  by  padding  in- 
side of  the  jacket  over  the  convexity 
of  the  curve  with  a  large  window  cut 
on  the  side  of  the  concavity. 

The  Cook  Strap. — The  use  of  a  broad  webbing  strap  passing 
around  the  convexity  of  the  spine  and  coming  out  of  a  large  window 
on  the  opposite  side  of  the  jacket  has  been  advocated  by  Cook^ 
and  possesses  certain  advantages  over  padding  in  removable  jackets 

^  "Am.  Journ.  of  Orth.  Surg.,"  July,  1913. 


Fig.  143.^ — Fenestrated  Jack- 
et Applied  to  Patient  with 
Lower  Dorsal  Curve  Strap  in 
Place.^ — {Ansel  G.  Cook.) 


174 


TREATMENT 


and  even  in  permanent  forcible  jackets.  It  is  easily  adjustable,  gives 
a  well-distributed  pressure  and  can  be  varied  by  the  position  of 
the  strap  to  attack  either  the  rotation  or  side  deviation.  In  con- 
nection with  a  large  window  on  the  concave  side  of  the  curve  it 
furnishes  a  powerful  means  of  constant  correction.  Cook  applies 
the  strap  to  a  jacket  with  large  windows  on  both  sides  but  the  writer 
has  found  the  best  use  of  the  strap  as  a  substitute  for  padding 
in  jackets  not  in  any  way  modified  from  the  usual  pattern. 


Fig.  144.- 


-Radiogram  of   Patient   Shown  in   Fig.    13S   after  Wearing  .Corrective 
Jacket  for,  over  one  Ye.a.r.     (March,  1907.) 


Jackets  of  either  kind  should  be  tested  for  efficiency  by  measuring 
the  height  of  the  patient  with  and  without  the  jacket.  Without  the 
jacket  the  patient  places  the  hands  on  the  hips  and  pushes  up,  mak- 
ing himself  as  tall  as  possible,  and  his  height  is  taken  in  this  posi- 
tion. The  jacket  is  then  applied  and  the  patient's  height  is  again 
taken.  If  the  jacket  does  not  hold  him  in  as  good  a  position  as  esti- 
mated by  the  greatest  height  the  patient  can  possibly  assume  with 


MECHANICAL   OBJECTIONS  1 75 

the  hands  on  the  hips,  it  is  discarded  and  a  more  corrective  one  is 
made. 

If  such  a  jacket  is  worn  by  a  patient  who  is  making  good  progress, 
in  a  few  weeks  from  the  beginning  of  treatment  it  will  be  found  to  be 
inefficient  and  not  to  be  holding  him  on  account  of  his  improvement. 
Under  these  conditions  the  torso  must  be  again  remodeled,  more  cut 
away  from  the  prominent  side  and  greater  pressure  exerted.     In  the 


Fig.  145. — Permanent  Corrective  Jacket  Applied. 

course  of  a  year,  probably  two  or  three  such  remodelings  would  be  re- 
quired. These  jackets  may  be  made  of  leather  or  celluloid  if  preferred 
rather  than  plaster,  but  the  plaster  is  perfectly  efficient,  although 
heavier. 

Mechanical  Objections  to  All  Corrective  Jackets. — In  applying 
force  to  correct  the  lateral  curve  and  rotation  of  the  scoliotic  spine  we 
cannot  apply  such  force  directly  to  the  spine,  but  we  must  apply  the 
corrective  pressure  to  the  ribs.  The  ribs  are  loosely  attached  to  the 
spine,  and  are,  moreover,  rather  easily  distorted  themselves  b}^  pres- 


176 


TREATMEXT 


sure.  We,  therefore,  must  do  without  that  direct  appHcation  of 
force  to  the  affected  structure  which  we  possess  in  the  treatment  of 
most  deformities. 

Secondly,  to  exert  effective  side  pressure  one  must  be  able  to 
press- laterally  not  only  against  the  apex  of  the  lateral  curve,  but  to 
exert  counterpressure  in  the  other  direction  at  the  top  and  bottom 
of  the  curve, ^  and  this  we  cannot  do  by  pressure  against  the  thorax 
in  high  dorsal  curves  because  we  cannot  reach  as  high  as  the  top 
of  the  curve.     To  attempt  to  secure  a  higher  level  of  side  counter- 


FiG.   146.  Fig.   147. 

Fig.  146. — Remodeled  Torso  Re.\dy  for  Application  of  Jacket. 
In  a  case  of  right  dorsal  left  lumbar  scoliosis  which  has  been  cut  in  two  at  the  waist  and 
set  apart  one  inch,  so  as  to  increase  the  upward  pressure  on  the  ribs.     The  dark  areas  on  left 
of  the  torso  show  where  plaster  has  been  added  on  the  concave  side  to  allow  for  correction 
of  displacement  and  deviation. — ("7.  Am.  Med.  Assoc") 

Fig.  147. — Front  of  Jacket,  made  over  Torso  Shown  in  Fig.   146.     Note  Shoulder 
Pad. — ("7.  Am.  Med.  Assoc") 

pressure  against  the  root  of  the  neck  is  to  pull  against  soft  structures 
overlying  a  nerve  plexus,  where  strong  pressure  is  not  tolerated,  nor 
can  side  pressure  be  exerted  on  the  lumbar  spine,  consequently  cor- 
rective jackets  are  not  satisfactory  in  lumbar  curves  or  in  curves 
whose  apex  is  as  high  as  the  upper  dorsal  region.  In  lower  dorsal 
and  dorsolumbar  curves  they  find  their  best  application. 

Thirdly,  forcible  jackets,  by  fixation  and  pressure,  cause  atrophy 
of  the  muscles  of  the  trunk  and  spine,  and  this  fact  has  been  much 
insisted  on  by  the  opponents  of  the  method.  But  when  the  time 
has  come  to  begin  the  after-treatment,  such  atrophy  is  quickly 

^F.  Lange:     "Zentrlblt.  ftir  chir.  and  mech.  orth.,"  Bd.  v,  Hft.  12. 


FORCIBLE   JACKETS 


177 


recovered  from  by  the  use  of  gymnastics  and  massage,  and  by 
the  gradual  rather  than  the  sudden  discontinuance  of  the  support 
when  the  proper  time  comes. 

That  such  jackets  will  prove  detrimental  to  the  general  health 
is  a  fear  which  is  not  supported  by  facts,  for  the  improved  posture 


Fig.  148. — Patient  in  Removable  Jacket.    Note  Window  on  Concave  Side.     Jacket 
Reinforced  by  Steel  Strips. 


and  the  restoration  of  the  viscera  to  a  more  normal  position  are 
more  than  enough  to  counterbalance  the  discomfort  and  the  handi- 
cap of  the  jacket,  in  the  great  majority  of  cases.     A  gain  in  flesh 


178 


TREATMEiNT 


and  improvement  in  the  general  condition  may,  as  a  rule,  be  pre- 
dicted from  the  appHcation  of  a  proper  jacket. 

Finally,  the  danger  to  life  from  the  application  of  jackets  may 
practically  be  disregarded.  Alarming  symptoms  have  arisen  and 
in  a  few  .instances  deaths  have  occurred  as  a  result,  but  in  these 
cases  the  use  of  force  has  been  too  great.     With  the  use  of  judgment 


Fig.  149. — Radiogram  of  Case  I  before  Treatment  by  Jackets  was  Begun, 


and  moderate  force  no  real   danger   can  be  incurred   in  normal 
individuals. 

Curves  due  to  congenital  defects,  infantile  paralysis,  rickets,  and 
empyema  are  available  for  forcible  correction,  those  from  infantile 
paralysis  being  often  among  the  most  satisfactory  in  their  results 
of  all  classes  of  moderate  and  severe  scoliosis. 


RESULTS  179 

Results. — The  author's  point  of  view  with  regard  to  results  to  be 
obtained  has  been  stated  under  prognosis  (i)age  127J  but  to  make  the 
matter  more  definite  the  personal  experience  of  the  author  in  a 
group  of  test  cases  is  here  given  with  a  view  of  placing  on  record  the 
x-rays  of  a  set  of  cases  carefully  observed  and  personally  treated. 

Six  cases  were  selected  from  the  Scoliosis  Clinic  of  the  Children's 
Hospital  for  treatment  in  the  fail  of  1914  and  the  photographs  and 


Fig.  150. — Radiogram  of  Case  I  after  Treatment  by  Jackets  as  Described 

X-rays  of  these  cases  were  made  under  the  supervision  of  the  Scoliosis 
Com.mittee  of  the  American  Orthopedic  Association  in  October.  In 
April  these  same  cases  were  again  presented  to  this  Committee  and 
their  records  again  taken  by  them.  These  cases  were  under  the 
personal  treatment  of  the  writer  by  whom  ail  jackets  were  applied. 


i8o 


TREATMENT 


When  it  seemed  advisable  they  were  Icept  in  the  hospital  for  longer 
or  shorter  periods.     Three  of  these  cases  are  here  presented. 

Case  I.— Boy,  five  years  old.  Colored.  Rachitic  scoliosis,  pre- 
viously treated  by  exercises.  Right  dorsal  left  lumbar  curvature. 
Treatment  was  begun  Nov.   23,  1914,  and  ended  in  April.     Four 


Fig.  151. — Radiogram  of  Case  II  before  Treatment  by  Permanent  Plaster 

Jackets. 

permanent  jackets  were  applied.  The  patient  is  still  under 
treatment  by  a  removable  jacket  and  exercises  (Figs.  149,  150). 

Case  2. — Girl,  eight  years  old,  scoliosis  due  to  infantile  paralysis. 
Deformity  noted  in  1910.  Curve,  left  cervicodorsal,  right  dorsal, 
left  dorsolumbar.  First  jacket  Oct.  29,  19 14.  Five  permanent 
plaster  jackets  (Figs.  151,  152). 

Case  3. — Boy,  eight  years  old,  etiology  not  determined.     Curve 


RESULTS 


I»I 


left   dorsolumbar.     First   jacket  Nov.  9,  19 14.     Four    permanent 
plaster  jackets  (Figs.  153,  154). 

As  the  study  concerned  itself  wholly  with  changes  in  the  spine  and 
not  with  changes  in  body  outline  only  x-rays  are  presented,  the 
photographs  being  omitted,  which  show  on  the  whole  much  more 


Fig.  152. 


-Radiogram  of  Case  II  after  Treatment  by  Permanent  Plaster 
Jackets. 


correction  than  is  indicated  by  the  x-rays.     The  x-rays  were  taken 
by  the  method  of  Bucholz  and  Osgood.^ 

A  further  case  is  given  showing  both  x-rays  and  photographs  to 
make  clear  the  point  that  great  change  in  body  outline  may  be 
secured  without  much  alternation  in  the  spinal  curve  as  shown  in 
the  x-rays  (Figs.  155,  156,  157,  158).    . 

i"Am.  Journ.  of  Orth.  Surgery,"  1914,  xii,  77. 


I«2 


TREATMENT 


Case  4. — Girl,  six  years  old,  curve  due  to  rickets,  deformity  noticed 
when  two  years  old.  Left  dorsolumbar  curve  treated  by  jackets 
since  May,  191 1.  First  photograph  Oct.,  191 1,  second,  April,  1915. 
Contemporaneous  a;-rays  showing  that  while  the  photograph  shows 
much  improvement,  the  spine  itself  has  been  nearly  stationary. 
(Figs.  155,  156,  157,  158). 


,^i:''^m^-/^^-;Ai:^fm^ 


Fig.  153. — Radiogram  of  Case  III  before  Treatment  by  Permanent  Plaster 

Jackets. 

Permanence  of  Results. — Successful  permanent  results  can  be  ob- 
tained in  hospital  practice  only  in  selected  cases,  the  average  patient 
being  unable  to  appreciate  the  importance  of  following  out  the  treat- 
ment sufi&ciently  long.  The  criticism  that  such  correction  is  not 
likely  to  be  permanent  at  once  presents  itself.  The  grounds  that 
lead  one  to  suppose  that  retention  of  the  growing  spine  in  a  corrected 
position  over  a  sufficient  period  will  lead  to  a  change  in  the  shape  of 


RESULTS 


183 


the  bones  of  the  vertebral  column  and  to  a  permanently  improved 
position  are  as  follows: 

(i)  Club-foot  may  be  cured  by  a  similar  proceeding. 

(2)  The  bones  of  the  feet  of  Chinese  women  of  rank  are  seriously 
misshapen  by  retention  in  ah  unnatural  position.^ 


Fig.  154. — Radiogram  of  Case  III  after  Treatment  by  Permanent  Plaster 

Jackets. 

(3)  Wullstein  produced  bony  changes  in  dogs  by  a  few  months  of 
abnormal  position. 

(4)  Arbuthnot  Lane  has^  demonstrated  that  the  carrying  of  heavy 
loads  by  laborers  will  produce  changes  in  the  bony  skeleton,  and  that 
the  changes  vary  according  to  the  habitual  position  of  the  load,  the 

1  P.  Brown:  "Jour.  Med.  Research,"  Dec,  1903. 
^  Guy's  Hosp.  Rep.,  xxviii. 


1 84 


TREATMENT 


bones    subject    to    the    greatest   pressure   undergoing    changes  in 
shape. 

(5)  The  fact  that  bone  under  pressure  changes  shape  after  growth 
has  been  reached  is  shown  in  the  fact  that  scar  tissue  pressing  on  bone 
will  cause  a  change  in  shape/  e.g.,  on  the  chin. 

(6)  Pressure  of  tumors  or  aneurysm  will  cause  absorption  of  bone. 
These  facts  all  point  to  the  conclusion  that  bone  alters  its  shape 

under  changed  conditions  of  pressure,  and  that  although  this  would 


Fig.  155.- — Case  IV  BEFORE  Treatment 
BY  Plaster  Jackets. 


Fig.  156. — Case  IV  after  Treatment 
BY  Plaster  Jackets. 


be  more  marked  during  growth,  the  phenomenon  is  not  unknown  in 
adult  life. 

It  seems  reasonable  to  hope  that  the  maintenance  of  improved 
position  may  be  expected  in  time  to  produce  a  change  in  the  shape 
of  the  vertebrae.  It  is  obvious  that  such  a  corrected  position  must 
be  maintained  over  a  period  of  many  months  to  secure  permanent 
results.  Schanz^  has  provided  clinical  evidence  that  his  results  have 
been  permanent  in  the  time  during  which  they  were  observed. 

1  Ziegler:  Pathology,  English  ed.,  1896,  ii,  146. 

2  "  Verhdlg.  d.  Deutsch.  Ges.  f.  orth.  Chir.,"  1908,  page  57. 


GYMNASTICS 


185 


Choice  of  Methods. — The  choice  between  the  use  of  fixed  or  re- 
movable corrective  jackets  must  be  determined  by  the  circum- 
stances of  the  patient,  the  temperament  of  the  child,  and  similar 
considerations.  Careless  hospital  patients  will  do  better  in  a  fixed 
jacket  for  a  year  or  two,  while  nervous  girls  in  private  practice  will  do 
better  in  spHt  jackets. 


Fig.  157. — Radiogram  of  Case  IV  before  Treatment  by  Permanent  Plaster 

Jackets. 

Gymnastics  Following  Forcible  Correction.— So  soon  as  the  final 
corrective  jacket  has  been  removed  and  replaced  by  a  removable 
one,  gymnastic  treatment  should  be  begun.  The  exercises  to  be  used 
have  been  described  in  the  section  on  Gymnastics.  Such  treatment 
to  accomplish  results  must  be  given  from  one  to  four  hours  a  dav  for 
a  period  of  at  least  six  months  from  the  removal  of  the  final  corrective 


i86 


TREATMENT 


jacket,  after  which  less  frequent  and  vigorous  exercises  may  be  suffi- 
cient. Exercises  must  be  continued  until  the  corrected  position  is 
maintained  without  apparatus  from  month  to  month,  and  the 
supporting  apparatus  discontinued  at  first  for  short  periods,  gradu- 
ally increasing  in  length.  The  length  of  time  that  active  treat- 
ment must  be  continued  will  depend  on  the  age  of  the  child,  the 


Fig.  158. — Radiogram  of  Case  IV  after  Treatment  by  Permanent  Plaster 

Jackets. 

severity  of  the  case,  the  efficiency  of  the  treatment,  and  similar 
factors,  but  any  case  of  scoliosis  severe  enough  to  require  forcible 
correction  will  not,  as  a  rule,  occupy  less  than  two  years,  and  often 
a  longer  period. 

The  present  discredit  of  gymnastic  retentive  treatment  is  due  to  its 
use  in  too  small  dosage  and  to  a  failure  to  appreciate  that  a  problem 


OPERATIVE   TREATMENT 


187 


SO  grave  as  the  permanent  maintenance  of  the  corrected  position 
in  a  spine,  which  has  suffered  some  degree  of  })ony  distortion,  is 
only  to  be  obtained  by  a  long  continuance  of  accurate  and  mechan- 
ically sound  treatment. 

Operation. — The  question  of  the  operative  relief  of  scoliosis  has 
been  for  the  present  abandoned.     An  operation  was  proposed  by 


Fig.    150. — Boy    Aged    12,    before 
Treatment. — {"J.  Am.  Med.  Assoc") 


Fig.  160. — -Boy  Aged  14,  after  Two 
Years'  Treatment  by  Means  •of  Per- 
manent Jackets  (see  Fig.  159). 


Volkmann^  in  1889,  consisting  of  resection  of  the  ribs  on  the  convex 
side  of  the  curve,  and  this  operation  was  also  performed  by  Casse- 
and  Hoffa^  with  fair  results.  A  similar  operation  was  thought  out 
by  N.  M.  Shaffer,  of  New  York,  about  fifteen  years  ago,  and  spoken 
of  to  the  writer  at  that  time  but  never  put  on  record,  as  the  general 
surgeons  to  whom  it  was  referred  refused  to  sanction  it.^ 

A  good  operative  correction  has  been  obtained  by  Hoke,^  of 
Atlanta,  Ga.,  who  resected  the  ribs  on  the  convex  side  of  a  girl  of 

1  Volkmann:  "Berl.  klin.  Wochens.,"  1889,  50. 

^Casse:  "Bull,  de  TAcad.  Royal  de  Med.  de  Belgique,"  Dec.  30,  i893;^Jaii. 
27,  1894. 

sHoffa:  "Zeitsch.  f.  orth.  Chir.,"  1896,  401. 
*  Shaffer:  "Amer.  Surg.  Bulletin,"  Jan.  i,  1S94. 
^  Hoke:  "Amer.  Jour,  of  Orth.  Surg.,"  i,  2. 


1 88  TREATMENT 

nineteen  and  lengthened  those  of  the  concave  side  in  a  severe  dorsal 
curve.  By  the  application  of  a  corrective  jacket  great  improvement 
was  obtained. 

Jaboulay'  divided  the  cartilage  of  a  single  rib  with  a  view  of  im- 


FiG.   i6i. — Girl  Aged   i6,  before  Treatment. — {"J.  Am.  Med.  Assn.") 

proving  the  shape  of  the  thorax.  Bade"'  has  reported  a  case  where  he 
resected  the  ribs,  but  cautions  against  the  use  of  narcosis  in  severe 
scoliosis. 

1  Jaboulay:   "Prog.  Med.,"  Nov.,  1893. 

-  Bade:  "  Klin.  Mittheil.  in  Centralbl.  f.  Cliir.,"  1903,  38,  1045. 


TREATMENT 


189 


Pig.  162. — Girl  Aged  18  after  Two  and  a  Half  Years'  Treatment  by  a  Series  of 
Permanent  Corrective  Jackets.     See  Fig.  161. — {"J.  Am.  Med.  Assn.") 


igo 


TREATMENT 


Fig.   163. 


Fig.   164. 


Fig.   165. 


Fig.   166.  Fig.   167. 

Figs.   163-167. — History  of  a  Case  of  Scoliosis  from  1903-1910. 
Figs.   163,    164. — 1903-5.     Increase  under  gymnastics  and  imperfect  jacket  treatment. 
Figs.   164,   165. — 1905-7.     Treatment  by  jackets  (one  forcible)  and  gymnastics. 
Figs.   165,   166. — 1907-9.     Left  clinic  and  had  gymnastics  twice  a  week  outside  with  no 
jacket. 

Figs.   166,   167. — 1909-10.     Returned  to  clinic  but  heart  displacement  was  so  great  that 
only  a  mild  brace  was  possible  with  no  gymnastics. 


CHAPTER  XIV 

FAULTY  ATTITUDE 

NORMAL  ATTITUDE 

In  addition  to  curves  to  the  side  in  the  spinal  column,  which  have 
been  described  as  scoliosis,  there  are  modiiications  of  the  normal 
forward  and  backward  spinal  curves  which  demand  consideration. 
Although  it  is  comparatively  easy  to  say  whether  or  not  a  patient  is 
normally  symmetrical  when  seen  from  the  back  it  is  not  so  easy  to  say 
whether  or  not  a  given  attitude  as  seen  from  the  side  is  normal  because 
there  is  no  generally  accepted  normal  attitude  in  the  standing  human 
figure  as  seen  from  the  side.  It  is  necessary  first  to  consider  those 
facts  which  are  known  with  regard  to  the  normal  attitude  before 
passing  on  to  analyze  its  abnormalities.  Normals  have  been  de- 
scribed by  Weber,  Meyer,  Langer,  Parow,  Henke,  Staffel  and  others, 
which  differ  much  among  themselves  as  would  have  been  expected, 
from  the  lack  of  a  uniform  or  satisfactory  system  of  measurement 
and  also  because  the  standing  position  is  influenced  by  sex,  age, 
race  and  occupation. 

As  the  problem  is  one  of  balance  from  the  feet  up,  it  is  evident  that 
any  reliable  method  of  analysis  must  take  into  account  the  base  of 
support  and  the  line  of  gravity  in  order  correctly  to  represent  the 
normal  standing  position  as  seen  from  the  side.  Merely  to  draw  a 
spinal  outline  and  construct  an  ideal  figure  without  regard  to  the 
relation  of  such  spinal  curve  to  the  legs  or  base  of  support  is  mis- 
leading. One  has  only  to  read  the  appended  literature  to  realize 
that  we  have  no  reliable  normal  of  the  standing  position  as  seen  from 
the  side.^ 

1  Borellius,  J.  A.:  "De  Motu  Animalium,  Lugduni  Batavorum,"  1679. 

Braune,  W.,  and  Fischer:  "Ueber  den  Schwerpunkt  des  menschlichen  Korpers, 
Abhandl.  d.  k.  Sachs.,"  "Akad.  d.  Wissensch.,  Math.-physik  Klasse,"  Leipsic, 
1889,  XV,  7. 

Dickinson,  R.  L. :  "The  Corset;  Questions  of  Pressure  and  Displacement," 
"New  York  Med.  Jour.,"  Nov.  5,  1887. 

Duchenne:  "Etude  physiologique  sur  la  courbure  lombo-sacree  et  de  I'inclina- 
tion  du  bassin  pendant  la  station  verticale,"  "Arch.  gen.  de  med.,"  series  6,  viii, 

534-  „  „^,      .     , 

Goldthwaite,  J.  E.:  "The  Influence  of  Pelvic  Joints  on  Posture,"  "Physical 
Education  Rev.,"  June,  1909. 

191 


192  FAULTY    ATTITUDE 

A  new  method  of  record  which  promises  to  enable  one  to  analyze 
the  normal  standing  position  and  its  abnormalities  is  that  of  Reynolds 
and  Lovett/  but  until  a  very  large  number  of  normal  studies  have 
been  made,  no  reliable  statement  of  what  the  normal  really  is,  can 
be  made,  and  no  very  accurate  information  can  yet  be  given  of 
variations  from  the  normal  in  this  plane.  This  method  gives  a  side 
elevation  of  the  erect  standing  position  of  the  individual,  with  at 
the  same  time,  the  position  of  the  line  of  gravity  in  its  relation  to 
the  body  and  to  the  base  of  support. 

On  the  platform  of  a  dial  scale  registering  up  to  100  pounds  is  placed  a  sharp 
edge  which  supports  one  end  of  a  flat  board  (B),  the  other  end  of  which  is  sup- 
ported by  a  similar  sharp  edge  placed  on  a  rigid  block  (C).  The  distance  be- 
tween the  edge  is  508  mm.  (20  inches).  A  short  distance  behind  the  rigid  block 
is  placed  an  upright  post  (E)  with  a  horizontal  sliding  arm  (D,  shown  in  section 
only),  which  furnishes  a  plane  of  reference  from  which  the  antero-posterior 
position  of  each  of  the  important  landmarks  of  the  body  can  be  determined  by 
measuring  their  horizontal  distance  from  this  sliding  arm  (Fig.  168). 

The  determination  of  the  antero-posterior  position  of  the  center  of  gravity 
in  the  standing  subject  is  made  as  follows: 

Goldthwaite:  "The  Relation  of  Posture  to  Human  Efiiciency,"  Borton: 
"ISIed.  and  Surg.  Journal,"  Dec.  9,  1909. 

Gerdy:  "Determination  des  levriers  que  forment  la  colonne  vertebrale,  les 
femurs  et  les  tibias  dans  I'attitude  verticale,"  "Rev.  med.,"  1834,  323. 

Horner,  F. :  "Ueber  die  Kriimmung  der  Wirbelsaiile  im  aufrechten  Stehen," 
"Inaug.  Diss.  Zurich,"  1854. 

Kellogg,  J.  H. :  "Experimental  Researches:  Relation  of  Dress  to  Pelvic  Dis- 
eases of  Women,"  "Tr.  Mich.  State  Med.  Soc,"  1888. 

Kellogg,  J.  H.:  "The  Relation  of  Static  Disturbances  of  the  Abdominal  Viscera 
to  Displacements  of  the  Pelvic  Organs,"  "Proc.  Internat.  Periodical  Cong. 
Gynec.  and  Obstet.,"  1892. 

Kohlrausch,  E.:  "Physik  des  Turnens  Hof.,"  1887,  page  17. 

Lane,  W.  Arbuthnot:  "Lancet,"  London,  Nov.  13,  1909. 

Meyer,  G.  H.:  "Die  Statik  und  Mechanik  des  menschlichen  Knochengerustes," 
Leipsic,  1873. 

Mosher,  Eliza  M.:  "The  Influence  of  Habitual  Posture  on  the  Symmetrj^  and 
Health  of  the  Body,"  "Brooklyn  Med.  Jour.,"  July,  1892. 

Mosso:  "Application  de  la  balance  d  I'etude  de  la  circulation  chez  I'homme," 
"Arch.  ital.  de  biol.,"  1884,  v.  131. 

Parrow,  W. :  "Studien  iiber  die  physikalischen  Bedingungen  der  aufrechten 
Stellung  und  der  normalen  Kriimmungen  der  Wirbelsaiile,"  "Virchows  Arch.  f. 
path.  Anat.,"  1864,  xxxi,  74. 

Schmidt:  "Unsere  Korper,"  1903,  page  63. 

Staffel,  F.  M.:  "  Die  menschlichen  Haltungstypen  und  ihre  Beziehung  zu  den 
Riickengratsverkriimmungen,"  Wiesbaden,  1889. 

Taylor,  C.  Fayette:  "Spinal  Irritation,  or  the  Causes  of  Backache  among 
American  Women,"  New  York,  William  Wood  and  Co.,  1870;  "Tr.  Med.  Soc, 
New  York,"  1864. 

Weber,  M.  and  E.:  "Mechanik  der  menschlichen  Gewerkzeuge,"  Gottingen, 
1836. 

^Reynolds,  E.,  and  Lovett,  R.  W.:  "Method  of  Determining  the  Position  of 
the  Center  of  Gravity  in  Its  Relation  to  Certain  Bony  Landmarks  in  the  Erect 
Position,"  "Am.  Jour.  Physiol,"  May  i,  1909;  "Jour.  Am.  Med.  Assn.,"  Mar. 
26,  1910. 


ANALYSIS    OF    UPRIGHT   POSITION 


193 


The  subject  is  weighed  on  an  ordinary  set  of  scales.  He  is  then  placed  on  the 
balance  plane  (B)  at  a  known  point  facing  the  scales.  (The  exact  point  is  un- 
important, but  after  experimentation  there  was  selected  as  most  convenient  that 
in  which  the  heels  are  situated  at  one-fourth  the  length  of  the  plane  from  the 
posterior  sharp  edge.)  A  removable  ledge  (F)  against  which  the  heels  are  placed 
is  provided  here. 

Since  the  balance  plane  on  which  the  subject  stands  acts  as  a  lever,  in  which 
the  weight  is  borne  between  the  fulcrum  (the  posterior  sharp  edge)  and  the  sup- 
porting" force  (the  spring  which  governs  the  scales),  it  is  evident  that  the  weight 
recorded  on  the  dial  (the  balanced  weight)  will  bear  to  the  total  weight  the  same 
proportion  as  that  which  obtains  between  the  total  length  of  the  balance  plane 
and  the  distance  between  the  perpendicular  dropped  from  the  patient's  center 
of  gravity  and  the  posterior  end  of  the  plane.     That  is:  As  the  total  weight  is  to 


-^ 


w. 


D 


Fig.  168. — Diagram  of  the  Apparatus  for  Estimating  the  Center  of  Gravity. 

A,  scale;  B,  balance  plane  on  which  patient  stands  facing  A;  C,  block  supporting  triangular 
edge;  D,  movable  horizontal  arm  on  upright  for  obtaining  horizontal  distances;  E,  vertical 
upright  for  standard  plane;  F,  ledge  against  which  heels  are  placed. — (^'American  Journal 
0}  Physiology.") 

the  balanced  weight,  so  is  the  total  length  of  the  board  to  the  horizontal  distance 
of  the  center  of  gravity  of  the  patient  from  the  posterior  sharp  edge  (the  ful- 
crum), or,  to  illustrate  by  a  specific  instance:  The  subject's  total  weight  is  140 
pounds;  when  placed  on  the  balance  plane  his  weight  is  50  pounds,  and  the  total 
length  of  the  board  is  20  inches. 
The  formula  reads  then: 

140  _  20 
50  X 

This  is  then  worked  out  as  follows : 

140)1000(7.1 
980 


The  center  of  gravity  of  the  subject  then  lies  perpendicularly  above  a  point 
7.1  inches  forward  from  the  posterior  sharp  edge. 
13 


194 


FAULTY    ATTITUDE 


After  the  determination  of  the  position  of  the  center  of  gravity,  which  should 
occupy  on  an  average  one  or  two  minutes,  the  position  of  the  following  points 
which  have  been  marked  on  the  skin  are  measured  and  recorded. 


Fig.  169. — Apparatus  in  Use.  The  Lines  Drawn  Represent  the  Lines  Shown  in 
THE  Record  Tracings.  The  Long  Line  Running  Vertically  is  the  Perpendicular  of 
THE  CexNter  of  Gravity. — {"J.  Am.  Med.  Assn.") 

I.  The  position  of  tlje  back  edge  of  the  malleolus.^ 

^  In  this  and  the  following  determinations  the  horizontal  difference  is  obtained 
by  a  footrule,  one  end  of  which  is  placed  against  the  marked  point,  while  the  body 
of  the  rule  is  held  by  the  thumb  against  the  upper  surface  of  the  sliding  arm. 
Since  this  surface  (and  therefore  necessarity  the  rule)  is  horizontal,  the  height  of 
the  point  observed  may  be  read  at  the  same  time,  from  a  graduated  scale  which 
is  marked  on  the  upright  post. 


NORMAL   ATTITUDE 


195 


y 


2.  The  position  of  the  back  of  the  head  of  the  fibula. 

3.  The  position  of  the  middle  of  the  trochanter. 

4.  The  position  of  the  posterior  part  of  the  spine  of  the  fifth  lumbar  vertebra. 

5.  The  position  of  the  posterior  part  of  the  spine  of  the  seventh  cervical 
vertebra. 

All  these  points  are  taken  under  the  usual  conventions  of  somatologic  measure- 
ments on  the  living. 

The  measurements  having  been  recorded,  are  then  easily  translated  into 
graphic  form  by  the  reproduction  of  the  observed  measurements  on  a  sheet  of 
paper,  of  which  the  bottom  represents  the  balance  plane 
and  the  edge  of  the  paper  the  posterior  plane  of 
measurement. 

These  five  comprise  all  the  exact  measurements  which 
are  taken,  but  since  the  value  of  their  graphic  represen- 
tation is  considerably  enhanced  by  its  combination  with 
some  sort  of  representation  of  the  body  profile  of  the  in- 
dividual, we  have  completed  the  examination  by  the 
use  of  a  device  which  obtains  this  with  fair  accuracy 
and  which  is  illustrated  in  Fig.  169. 

A  series  of  horizontal  metal  arms,  tipped  with  cellu- 
loid, slide  easily  through  holes  in  the  vertical  wooden 
arm.  These  metal  arms  are  shaken  out  to  their  full 
length,  and  their  ends  pushed  rapidly  and  lightly  against 
the  subject's  back  in  the  median  line,  the  point  of  the 
uppermost  horizontal  arm  being  applied  to  the  seventh 
cervical  vertebra.  In  the  construction  of  the  graphic 
record  (Fig.  170),  the  position  of  this  profile  is  known 
by  its  relation  to  the  seventh  cervical  and  fifth  lumbar 
vertebrae;  that  is,  these  points  are  marked  on  the  paper 
from  the  measurements  taken,  and  the  end  of  the  upper- 
most arm  of  the  profile  instrument  is  laid  against  the 
mark  which  represents  the  seventh  cervical,  while  a 
lower  point  is  in  contact  with  the  mark  representing  the 
fifth  lumbar  vertebra.  The  curve  is  then  traced  on  the 
paper  containing  the  other  measurements  from  the  ends 
of  the  pins  throughout  its  length. 

The  body  curve  of  the  ventral  surface  is  obtained  in 
the  same  way.  The  uppermost  arm  of  the  profile  in- 
strument is  applied  to  the  anterior  surface  of  the  neck  at 
the  level  of  the  seventh  cervical  vertebra.  The  position 
of  this  curve  on  the  chart  is  ascertained  by  using  as  points  of  reference  the 
horizontal  distances  between  the  posterior  parts  of  the  seventh  cervical  and 
fifth  lumbar  vertebrae  and  the  points  horizontally  opposite  on  the  ventral 
surface,  measured  on  the  subject  by  a  pelvimeter  or  other  calipers. 

It  would  be  very  desirable  that  this  graphic  record  should  be  completed  in 
every  instance  by  a  representation  of  the  inclination  of  the  brim  of  the  pelvis, 
which  would,  of  course,  include  its  relation  to  the  trochanter,  but  after  much 
experimentation  we  have  been  unable  to  measure  with  accuracy  the  inclination 
of  the  pelvic  brim  in  the  living  subject. 


Fig.  170. — Record 
OF  THE  Normal  Posi- 
tion AND  THAT  IN- 
DUCED BY  High-heeled 
Shoes,  the  Normal  in 
Solid  Line,  the  In- 
duced Position  in 
Dotted  Line.- — ("7. 
Am.  Med.  Assn.") 


196  FAULTY   ATTITUDE 

The  use  of  the  profile  curves  in  the  graphic  representation  involves  the  dis- 
advantage that  the  chart  must  be  drawn  life-size,  but  it  can  be  reduced  later  by  a 
pantograph  to  any  desired  size. 

The  sources  of  error  incident  to  the  method  are  swaying  of  the  subject,  errors 
in  measurement  from  the  vertical  plane,  distortion  of  attitude  during  observation, 
inaccuracy  in  locating  on  the  skin  the  bony  landmarks  selected,  varying  position 
of  the  feet,  horizontal  rotation  of  the  pelvis  and  psychical  influences.  These 
errors  and  their  prevention  are  dealt  with  at  some  length  in  the  original  descrip- 
tion of  the  method. 


So  far  as  the  observations  by  this  method  have  gone  they  show  that 
in  the  erect  positipn  the  center  of  gravity  of  the  body  lies  in  front  of 
the  ankle-joints,  which  are  held  from  dorsal  flexion  in  this  position 
by  the  gastrocnemius  muscles.  The  center  of  gravity  lies  also  in 
front  of  the  knees,  which  are  similarly  held  in  position  by  the  ham- 
string and  quadriceps  extensor  muscles.  The  center  of  gravity 
lies  also  anterior  to  the  sacro-iliac  joints  and  most  of  the  vertebral 
joints.  The  position  of  the  acetabula  cannot  be  determined  in  the 
erect  position  in  the  living  individual  because  we  have  no  means 
of  locating  them  from  any  available  landmarks.  If  we  were  able 
to  determine  the  position  of  the  acetabula  in  the  antero-posterior 
plane  it  would  be  possible  to  state  definitely,  from  the  relation  of 
the  center  of  gravity  to  them,  whether  the  trunk  in  the  erect  position 
would  tend  to  fall  forward  or  backward  at  their  level.  But  from 
the  impossibility  of  obtaining  definite  data  on  this  point  we  are 
obliged  to  resort  to  another  line  of  observations  to  determine  this 
matter. 

It  has  been  shown  by  many  experiments  that  when  the  cadaver  is 
stood  erect  and  the  legs  and  ankles  are  fixed  (to  prevent  the  cadaver 
from  collapsing  on  the  ground),  the  trunk  falls  forward  from  the  hips. 
In  the  erect  position  then,  the  trunk  is  held  extended  on  the  legs  by  the 
combined  and  continued  action  of  the  posterior  musculature,  the  chief 
factors  here  being  the  hamstrings,  the  glutei  and  the  erector  spinas 
muscles. 

After  a  consideration  of  this  theoretical  side  of  the  subject  which 
will  in  time  enable  us  to  obtain  exact  information  as  to  abnormalities 
of  the  standing  position  it  becomes  necessary  to  formulate  our 
present  knowledge  with  regard  to  these  abnormalities. 

When  the  antero-posterior  and  lateral  variations  coexist,  as 
frequently  happens,  the  lateral  variation  is  in  general  considered  the 
more  important  one,  and  the  case  is  classed  as  scoliosis. 


ROUND    SHOULDERS 
ROUND  SHOULDERS 


197 


.  Stoop  or  slant  shoulders,  round  back,  round  hollow  back,  stoop- 
ing, faulty  attitude,  kyphosis,  bowed  back. 

German — Schlechte  Haltung,  runde  Riicken,  Kyphose,  hohlrunde 
Riicken,  kypholordose,  habituelle  Kyphose. 

French — Dos  Voute,  Cyphose. 

Italian — Schiene  rotonde. 


Fig.  171. — Round  Back  with  Flat  Chest  and  Prominent  Abdomen. 

Grouped  under  this  name  are  various  types  of  faulty  attitude. 
Variations  from  the  normal  antero-posterior  attitude  are  in  general 
grouped  under  the  name  of  round  shoulders.  These  shade  into  each 
other  and  are  characterized  by  a  disposition  to  economize  muscular 
force  in  maintaining  the  erect  position.     These  deviations  have  in 


igS  FAULTY   ATTITUDE 

general  been  grouped  as  round  shoulders  because  an  increased  con- 
vexity of  the  dorsal  spine  is  the  most  common  characteristic. 

In  general  the  attitude  is  familiar,  the  head  is  carried  forward  and 
is  somewhat  flexed,  the  physiological  curve  in  the  dorsal  region  is 
increased  and  the  dorsal  region  unduly  prominent  behind,  in  which 
backward  curve  the  lumbar  region  may  share,  or  there  may  be  also 
an  increased  lumbar  curve  forward.  The  shoulders  are  drooping 
and  the  chest  narrow  and  flat,  while  the  scapulas  behind  are  promi- 
nent on  their  posterior  borders  and  the  inferior  angles  may  stick 
out  markedly  (scapulae  alatae).  The  abdomen  is  prominent,  es- 
pecially in  its  lower  part.  Flat-foot  or  pronated  foot  frequently 
coexists. 

Children  with  round  shoulders  are,  as  a  rule,  below  the  average  in 
muscular  development  and  lack  vigor;  they  are  clumsy  in  their  move- 
ments and  walk  heavily.  In  some  cases  the  deformity  can  be  re- 
moved by  a  muscular  effort  on  the  part  of  the  patient  or  by  gentle 
pressure  with  the  hands,  but  in  most  cases  of  even  average  severity 
the  deformity  cannot  be  wholly  corrected  by  gentle  passive  force,  as 
the  maintenance  of  the  malposition  has  led  to  adaptive  shortening  of 
the  soft  parts  concerned.  The  cases  may,  therefore,  be  considered 
as  flexible  or  resistant,  an  important  distinction  in  treatment.  Great 
injustice  is  done  to  children  with  resistant  round  shoulders  by  the 
continual  commands  to  "sit  straight,"  a  position  which  it  is  im- 
possible for  them  to  assume. 

If  such  a  child  is  laid  face  downward  on  a  table  with  the  arms  at 
right  angles  to  the  body  the  arms  may  by  passive  force  be  carried  back 
of  the  middle  line  of  the  body.  If  in  this  position  the  arms  are 
carried  up  beside  the  head  and  then  lifted  back  they  cannot  as  a 
rule  be  carried  so  far  as  the  median  plane  of  the  body.  If  such  a 
child  is  told  to  put  the  arms  up  in  the  air  in  the  standing-position,  it 
is  done  by  making  the  back  hollow  in  the  lower  part  and  protruding 
the  abdomen,  because  the  soft  parts  between  the  chest  and  arms 
have  become  contracted  and  do  not  permit  a  free  movement.^ 
Lateral  curvature  of  the  spine  frequently  coexists. 

The  affection  is  not  wholly  one  of  the  spine,  but  implies  a  disturb- 
ance of  relations  from  the  feet  upward  because  an  increase  in  the 
backward  curve  of  the  spine  implies  a  forward  curve  or  forward  dis- 
placement somewhere  else  to  balance  it.  The  dorsal  spine  in  other 
words  cannot  become  more  convex  without  a  compensating  lumbar 

1  E.  H.  Bradford:  "Round  Shoulders,"  "Orth.  Trans.,"  vol.  x,  page  162. 


ROUND   BACK 


199 


curve  forward,  or  a  forward  displacement  of  the  pelvis  and  legs  if  the 
lumbar  spine  is  involved  in  the  backward  dorsal  curve. 

Round  shoulders,  therefore,  is  not  to  be  considered  or  treated  as 
an  affair  wholly  concerning  the  dorsal  spine  and  shoulders.  On 
closer  analysis  these  cases  will  be  found  to  fall  into  four  not  very  well- 
d6fined  groups.  Transition  cases  of  all  grades  are  seen,  and  the 
division  is  mentioned  simply  to  aid  in  the  study  of  the  cases  and  their 
treatment.     The  groups  are  as  follows: 


Fig.   172. — Round  Back. 


1.  Round  Back. — The  dorsal  and  lumbar  spine  form  one  convexity 
backward,  which  is  physiologically  a  persistence  of  the  infantile 
position  (page  21).  A  lordosis  is  apparently  of  ten  present,  but  on 
identifying  the  landmarks  this  will  be  found  to  be  merely  the  up- 
ward and  forward  slope  of  the  sacrum  and  that  the  lumbar  spine 
does  not  share  in  it. 

2.  Round  Hollow  Back.— The  dorsal  spine  is  bowed  backward, 
but  the  lumbar  spine  is  bowed  forward.  The  appearance  of  round 
shoulders  is  present,  but  the  general  attitude  is  modified  because  the 


200 


FAULTY   ATTITUDE 


pelvis  apparently  has  a  greater  inclination  than  in  round  back,  the 

abdomen  is  prominent,  and  the  gross  appearance  is  the  same  as  in 

round  back  (Fig.  173). 

3.  Round  Upper  Back. — In  certain  cases  the  dorsal  backward 

curve  occurs  in  the  upper  part  of  the  spine  and  gives  an  especially 

noticeable  forward  thrust  to  the 
head  and  a  prominence  between 
the     scapulae.     These    cases    are 


Fig.   173. — Round  Hollow  Back. 


Fig.  174. — -Round  Upper  Back. 


rather  likely  to  be  rigid  and  respiratory  capacity  is  poor.  The 
lumbar  physiological  curve  is  not  necessarily  abnormal  (Fig.  174). 
4.  Flat  Back. — In  certain  cases  the  vertebral  column  is  flat  and 
has  apparently  nearly  lost  its  dorsal  and  lumbar  physiological  curves. 
The  pelvic  inclination  is  obviously  diminished  and  a  frequent  associa- 
tion with  this  attitude  is  a  forward  resistant  position  of  the  shoulders.  ^ 
This  forward  position  of  the  shoulder  girdle  may,  however,  ac- 


^  Hasebrook:  "Zeitsch.  f.  orth.  Chir.,"  xii,  4,  613. 


ETIOLOGY  20I 

company  other  forms  of  antero-posterior  deviation,  such  as  round 
back. 

In  certain  cases  as  noted  by  Haglund^  the  back  is  rounded  from 
side  to  side  without  especial  kyphosis. 

It  must  be  recognized  how  very  superficial  and  unsatisfactory  this 
classification  is  and  it  must  be  evident  that  we  are  a  long  way  from 
recognizing  the  essentials  which  cause  this  condition.  For  purposes 
of  discussion  these  four  divisions  will  still  be  spoken  of  as  round 
shoulders  in  spite  of  the  fact  that  this  is  merely  one  expression  of 
faulty  antero-posterior  attitude  which  involves  the  whole  body  from 
the  base  of  support  to  the  head. 

ETIOLOGY 

The  shape  of  the  figure  is  as  characteristic  of  the  individual  as  the 
form  of  the  features  and  some  children  inherit  straighter  spines  than 
others.  A  certain  amount  of  importance  must  therefore  be  attached 
to  the  type  of  spine  with  which  the  child  starts.  Further  evidence 
of  a  congenital  origin  of  round  shoulders  than  this  (except  in  gross 
congenital  lesions  of  the  spine),  is  on  the  whole  wanting. 

In  general  the  causes  of  round  shoulders  are  to  be  sought  in — (a) 
conditions  causing  muscular  weakness;  (b)  conditions  causing  a  flexed 
position  of  the  spine  for  long  periods,  and  in  (c)  overweighting  of  the 
shoulders  by  improperly  arranged  clothing;  (d)  rickets.  Some 
German  writers  incline  toward  the  view  that  a  weakness  of  the  will 
is  a  more  important  cause  than  weakness  of  the  muscles. 

a.  Conditions  causing  muscular  weakness  are  found  in  rapid 
growth,  overwork  and  bad  air  at  school,  improper  school  furniture, 
acute  illness,  bad  hygiene  at  home,  and  similar  conditions. 

b.  Prolonged  flexion  of  the  spine  is  induced  by  school  furniture 
which  fails  to  support  the  back,  by  errors  in  vision  which  necessitate 
stooping  over  the  books  in  reading,  and  in  careless  attitudes  of  reading 
and  sitting  permitted  at  home.  The  child  with  normal  eyes  should 
not  have  to  hold  the  book  nearer  than  twelve  to  fourteen  inches. 

c.  The  customary  method  of  supporting  a  child's  clothes  in  this 
community  consists  in  the  use  of  a  waist,  loose  around  the  abdomen, 
to  which  drawers  and  skirts  or  trousers  are  buttoned.^  To  this  waist 
are  also  attached  side  elastic  stocking  supporters  which  are  kept  tight 
to  prevent  the  stockings  from  wrinkling.     This  waist  is  supported 

1  Haglund:  "Zeitsch.  f.  orth.  Chir.,"  xxv,  649. 

2  Bradford:  "Orth.  Trans.,"  vol.  x,  162;  Goldthwait:  "Amer.  Jour,  of  Orth. 
Surg.,"  vol.  i,  64. 


202 


FAULTY    ATTITUDE 


above  by  two  shoulder-straps  passing  over  the  shoulders  near  their 
tips.  The  whole  weight  of  the  clothes  and  the  added  pull  of  stout 
elastics  is  thus  transferred  to  the  child's  movable  shoulders,  of  all 
parts  of  the  body  the  least  suited  to  hold  against  a  steady  downward 
pull.  This  pull  is  transferred  in  a  measure  to  the  spine  by  the 
muscles,  clavicles,  and  thorax,  and  tends  to  produce  flexion. 

The  remedy  of  this  condition 
\\  consists  in  supporting  as  much  as 
;,  possible  the  clothing  from  a  belt, 
i;    using  round  garters,   or  in  cases 


<jiii$. 


Fig.    175.-— Flat    Back;  Forward  Posi- 
tion' OF  THE  Shoulder-girdle. 


Fig.   176. — Waist  with  Garters  Pull- 
ing Shoulders  Down  and  Forward. 


with  markedly  prominent  abdomens  the  use  of  the  corset  waist  to 
be  described. 

OCCURRENCE 


In  examinations  of  school  children  the  observers  find  antero- 
posterior curves  less  frequent  than  lateral,  but  as  before  explained  it 
is  often  impossible  to  say  what  is  an  antero-posterior  curve  and 
what  is  a  normal. 

At  Stockholm,  Haglund  found,  in  1599  children,  280  scolioses  and 
170  antero-posterior  curves  (90  boys  and  80  girls). 


PROGNOSIS  203 

The  Lausanne  series  of  2314  children  showed  571  scolioses  (24.6 
per  cent.)  and  135  antero-posterior  curves  (5.8  per  cent.),  with  47 
combined  cases  included  in  the  above. 

Gronberg   found    715    antero-posterior   curves   in   8250   Finnish 
children.    They  were  divided  as  follows  according  to  his  classification : 
Kyphosis  (round  back),  478  (66.9  per  cent.). 
Kypho-lordosis  (round  hollow  back),  149  (20.8  per  cent.). 
Lordosis  (hollow  back),  88  (12.3  per  cent.). 
The  age  of  occurrence  of  round  shoulders  covers  the  period  of 
childhood  from  shortly  after  the  time  that  walking  begins  to  adoles- 
cence; most  cases  are  seen  by  the  surgeon  in  middle  childhood  and 
about  puberty,  when  in  girls  especial  attention  is  paid  to  the  figure 
and  carriage. 

PATHOLOGY  AND  MECHANISM 

The  pathological  changes  in  round  shoulders  must  be  determined 
rather  by  inference  and  interpretation  of  clinical  symptoms  than  by 
postmortem  examination. 

Permanent  kyphosis  in  a  healthy  growing  dog  was  produced  ex- 
perimentally by  Wullstein,  who  approximated  the  pelvis  and 
shoulders  by  straps,  causing  a  flexed  position  of  the  spine.  In 
children  who  continue  to  grow  with  the  spine  in  flexion,  analogous 
adaptive  changes  must  occur  in  the  spine  and  its  surrounding  struc- 
tures to  those  found  in  scoliosis. 

Hasebrook^  considered  the  cause  of  resistant  forward  displace- 
ment of  the  shoulders  to  lie  partly  in  the  costoclavicular  and  coraco- 
clavicular  ligaments  and  partly  in  the  pectoralis  and  serratus  muscles. 
He  divided  the  cases  into  two  groups-^first,  those  due  to  contrac- 
tion of  the  muscles  holding  the  shoulders  forward,  and,  second,  to 
weakness  of  the  muscles  holding  them  back.  In  certain  cases, 
however,  it  is  due  to  malformation  of  the  upper  part  of  the  scapulae 
which  prevents  their  approximation  to  the  middle  line  behind. 

PROGNOSIS 

The  attitude  of  round  shoulders  is  not  to  be  regarded  as  one  which 
will  be  spontaneously  outgrown.  On  the  other  hand,  it  requires 
treatment,  and  with  adequate  treatment  and  proper  hygiene  the 
prognosis  for  recovery  is  good  in  young  children.  In  older  children 
and  adolescents  improvement  and  perhaps   cure   are   to  be  ob- 

^"Zeitsch.  f.  orth.  Chir.,"  xii,  4,  613. 


204  FAULTY   ATTITUDE 

tained.  Even  in  young  adults  an  improved  position  of  the  shoulders 
and  a  better  expansion  of  the  chest  are  to  be  secured  by  adequate 
treatment. 

If  the  attitude  of  round  shoulders  is  allowed  to  persist  into  adult 
life  there  are  certain  respects  in  which  it  may  affect  unfavorably  the 
health  of  the  individual.  The  flat  chest  and  diminished  chest 
capacity  mean  impaired  respiratory  capacity,  and  diminished  room 
for  the  heart,  and  the  large  abdomen  favors  ptosis  of  the  abdominal 
viscera,  both  factors  leading  to  impaired  efficiency.^  Moreover,  the 
bowed  spine  is  generally  a  weak  spine  and  such  patients  are  liable 
to  static  backache,^  that  is,  a  backache  due  to  strain  of  the  posterior 
muscles  described  under  the  names  of  "hysterical  spine,"  "irritable 
spine,"  etc. 

DIAGNOSIS 

The  diagnosis  of  round  shoulders,  when  it  is  present  in  any  marked 
degree,  as  a  rule,  presents  no  difficulty,  but  at  times  it  is  not  easily 
distinguished  from  more  serious  affections,  causing  a  backward  bow- 
ing of  the  spine.  The  means  of  distinguishing  between  the  different 
varieties  of  round  shoulders  have  been  sufficiently  indicated  in  the 
description  of  them.  The  important  point  is  to  distinguish  a  static 
bowing  of  the  spine  from  one  caused  by  disease.  In  the  former  there 
is  no  marked  stiffness  of  the  spine,  pain  is  absent,  the  bowing  is 
gradual,  and  x-Ta.y  appearances  are  normal. 

Differential  Diagnosis. — Pott's  disease  (tuberculosis  of  the  spine, 
angular  curvature  of  the  spine)  was  discussed  in  speaking  of  the  diag- 
nosis of  scoliosis.  At  certain  stages  of  dorsal  Pott's  disease  the 
attitude  may  resemble  round  shoulders.  Arthritis  deformans  of  the 
spine  was  discussed  under  the  diagnosis  of  scoliosis. 

No  gymnastic  treatment  for  a  case  of  round  shoulders  should  be 
undertaken  in  a  patient  where  pain  or  stiffness  of  the  back  is  present 
without  a  very  careful  preliminary  period  of  observation  and  a 
careful  elimination  of  the  first  two  conditions  mentioned  above. 

TREATMENT 

The  treatment  of  round  shoulders  is  different  in  flexible  or  non- 
resistant  cases  and  in  resistant  cases. 
Non-resistant  Round  Shoulders  (Flexible  Round  Shoulders). — 

The  treatment  does  not  differ  radically  from  that  of  postural  sco- 

^  Goldthwait  &  Brown:  "Am.  Journ.  of  Orth.  Surgery,"  Nov.,  1911. 
2  Reynolds  and  Lovett:  Zoc.  cit.  "Journ.  Med.  Assoc,"  Mar.  26,  1910. 


TREATMENT 


(" 


20: 


liosis  in  that  both  are  of  the  type  of  the  "setting-up  drill"  of  the 
army  recruit.  In  both,  one  tries  to  substitute  a  correct  attitude  for 
the  incorrect  or  faulty  one.  What  has  been  said  with  regard  to  the 
treatment  of  postural  or  functional  scoliosis  applies  to  the  treatment 
of  flexible  round  shoulders,  the  routine  and  exercises  being  described 
in  that  place  (140)  for  both  conditions,  and  certain  exercises  being 
being  designated  as  especially  adapted  to  round  shoulders. 

Resistant  Round  Shoulders. — The  treatment  of  these  cases  is 
similar  in  plan  to  that  of  structural  scoliosis  where  first  mobilizing 


i 

^■'''\' 

Fig.  177. — Apparatus  for  Stretching  Round  Shoulders  and  for  the  Application  of 

Forcible  Jackets. 


and  then  retentive  measures  must  be  separately  recognized,  even 
if  both  are  carried  out  simultaneously. 

Mobilization. — When  the  shoulders  are  held  forward  by  contrac- 
tion of  the  soft  parts  and  cannot  easily  be  replaced  in  the  normal 
position,  simple  gymnastics  are  likely  to  prove  unsatisfactory  and 
some  stretching  of  the  contracted  parts  is  necessary  in  order  to  save 
time  and  make  gymnastics  more  effective.  To  stretch  these  soft 
parts  by  gymnastic  exercises  is  slow  and  often  unsatisfactory,  and 


206  FAULTY   ATTITUDE 

when  it  is  done  must  be  accomplished  by  passive  stretching,  induced 
by  pulling  back  the  shoulders  either  with  the  arms  at  the  sides  or 
on  a  level  with  the  shoulders,  whichever  position  offers  the  greatest 
resistance. 

Passive  stretching,  however,  by  means  of  an  apparatus  is  more 
efficient  and  quicker.  The  means  to  be  described  offers  a  simple 
method. 

The  apparatus  consists  of  an  oblong  gas-pipe  frame  of  the  ordinary  pattern. 
Fastened  to  this  near  the  middle,  and  hinged  so  as  to  be  raised  to  any  degree,  is 
another  section  of  gas-pipe  lying  on  the  frame  proper  and  of  the  same  shape  and 
size  as  the  upper  half  of  the  frame.  To  this  movable  section  is  fastened,  at  right 
angles  to  it,  and  movable  on  it,  a  gas-pipe  bridge  rising  about  eighteen  inches  from 
the  movable  section  (Fig.  177). 

When  prepared  for  use  two  strips  of  webbing,  lying  one  over  the  other,  run 
from  each  of  the  buckles  at  the  bottom  of  the  frame.  The  lower  two  strips  are 
tightly  drawn,  and  run  to  the  buckles  at  the  end  of  the  movable  section.  The 
upper  two  are  loosely  fastened  to  the  bridge  over  the  movable  section.  The  cross- 
pieces  are  tightened  and  the  patient  laid  face  downward  on  the  webbing  strips, 
which  may,  if  desired,  have  laid  over  them  a  folded  piece  of  sheet  wadding.  The 
strips,  however,  even  in  adults,  are  not  uncomfortable.  The  thighs  are  flexed 
and  the  feet  rest  on  the  floor,  so  that  the  lumbar  spine  is  flattened.  Two  pieces 
of  webbing  are  passed  over  the  mid-dorsal  region  from  side  to  side,  tied  to  the 
lower  non-movable  frame  on  each  side.  These  furnish  the  resistance  for  the 
straightening  of  the  spine  when  the  upper  end  of  the  frame  is  lifted,  carrying  with 
it  the  head  and  upper  chest.  The  upper  part  of  the  frame  is  lifted  after  the 
patient  is  in  place  and  as  much  force  as  seems  advisable  is  exerted.  This  should 
never  be  pushed  beyond  the  point  of  mild  discomfort.  Several  stretchings  are 
first  made  of  a  few  seconds  each,  and  the  movable  part  of  the  frame  again  let 
down  to  rest  the  patient. 

Forcible  Correction. — In  average  cases  intermittent  stretching  is 
sufficient  to  loosen  up  the  contraction  and  to  make  an  improved 
position  possible.  In  the  severer  cases,  however,  a  plaster  jacket 
should  be  applied  in  the  improved  position. 

The  patient's  spine  is  hyperextended  as  described,  by  raising  the 
movable  part  of  the  framej  which  is  then  fastened  in  this  position  and 
a  plaster-of-Paris  jacket  applied,  including  the  shoulders,  which  must 
be  well  padded  by  felt  on  their  anterior  surface.  This  jacket  holds 
the  dorsal  spine  somewhat  extended^  and  the  shoulders  back,  by  firm 
pressure,  and  the  pressure  can  be  increased  from  day  to  day  by  in- 
serting more  felt  between  the  jacket  and  the  shoulders. 

Such  jackets  should  be  worn  from  two  to  four  weeks,  and  on  their 
removal  efficient  gymnastic  work  begun,  supplemented  by  braces,  if 
necessary,  to  hold  the  improved  position  between  treatments. 

^  R.  W.  Lovett:  "Amer.  Jour,  of  Orth.  Sur.,"  ii,  2,  200. 


TREATMENT 


207 


The  use  of  corrective  or  retentive  braces  in  round  shoulders  is  often 
unsatisfactory  because  they  are,  as  a  rule,  constructed  only  to  f)ull  the 
scapulae  and  arms  backward,  without  making  efificient  forward  pres- 
sure on  the  curved  dorsal  spine  or  making  any  marked  improve- 
ment in  the  general  attitude.  The  "  shoulder  braces "  sold  in  the 
instrument  shops  are  notably  unsatisfactory  in  most  cases. 


Fig.  178. — Corset-waist  for  the  Treatment  of  Round  Shoulders. 

In  flexible  cases  of  moderate  grade  or  in  rigid  cases  of  the  same 
degree  which  have  been  made  flexible,  a  properly  constructed  corset- 
waist  to  support  the  abdomen  has,  in  the  experience  of  the  writer,  in 
many  cases  proved  more  satisfactory  than  a  brace  in  inducing  an  im- 
proved attitude.  The  abdominal  element  in  these  cases  has  been 
too  much  overlooked  and  the  relaxed  and  stretched  abdominal  wall  is 
a  very  important  feature  of  the  symptom-complex  roughly  called 
"round  shoulders." 


2o8 


FAULTY   ATTITUDE 


Efficient  abdominal  support  by  means  of  a  corset-waist  not  only 
enables  the  stretched  abdominal  muscles  to  shorten  and  recover 
tone,  but  by  supporting  the  abdominal  contents  enables  the  patient 
to  assume  a  better  general  position.  A  better  position  of  the  thorax 
at  once  becomes  easier  and  the  whole  attitude  is  improved. 


,FiG.  179. — Round    Shoulders    before 
Forcible  Correction. 


Pig.  180. — Round  Shoulders  after 
Treatment  Follovving  Forcible  Cor- 
rection.   See  Fig.  153. 


Such  corset- waists  should  fit  tightest  around  the  bottom  just 
above  the  trochanters  and  should  diminish  in  pressure  from  below 
upward,  the  upper  part  of  the  abdomen  being  free  from  constriction. 
They  should  button  in  front  but  be  laced  in  the  back,  and  from  them 
may  be  hung  skirts  and  stockings. 

There  is  no  objection  to  their  use  in  young  children  and  the  fear  of 
the  parents  that  they  will  "weaken"  the  abdominal  wall  will  be  dis- 
pelled as  soon  as  the  improved  abdominal  outline  is  seen  after  a  short 


TREATMENT  209 

use  of  them.     They  should  be  used,  of  course,  only  in  connection  with 
and  accessory  to  gymnastic  treatment  (Fig.  178). 

Corsets  and  Braces. — The  use  of  supports  to  maintain  the  spine  in 
a  correct  position  is  indicated — (i)  in  the  case  of  children  with  lax 
muscles  who  are  unable  to  hold  an  erect  position  between  gymnastic 
tieatments;  (2)  after  forcible  correction  to  retain  what  has  been 
gained;  and,  (3)  in  resistant  cases  which  are  being  stretched;  but 
which  cannot  maintain  between  stretchings  the  improvement  se- 
cured by  each  one.  In  all  of  these  the  brace  is  to  be  regarded  as  a 
temporary  measure,  supplementary  to  the  other  treatment,  whether 
gymnastic  or  mobilizing,  and  to  be  given  up  as  soon  as  it  can  be  dis- 
pensed with.  As  the  sole  treatment  of  resistant  round  shoulders 
the  use  of  a  brace,  which  by  its  corrective  effect  is  to  cure  the 
malposition,  is  not  to  be  advised.  The  brace  which,  on  the  whole, 
is  the  most  generally  effective  is  the  tempered  steel  upright  support. 
It  is  made  as  follows: 

This  form  of  apparatus  consists  of  (o)  a  horizontal  pelvic  band,  (b)  two  up- 
rights, and  (c)  a  cross-bar. 

a.  The  horizontal  pelvic  band  encircles  the  posterior  part  of  the  pelvis  from 
a  point  one  inch  posterior  to  the  anterior  superior  spine  on  one  side  to  a  similar 
point  on  the  other  side.  It  is  curved  to  fit  the  contour  of  the  pelvis  and  should 
lie  close  against  it.  It  is  made  of  No.  15  gauge  sheet  steel,  one  and  one-eighth 
inches  wide.  The  uprights  run  from  the  posterior  pelvic  band  along  the  sides 
of  the  spine  to  a  point  about  on  a  level  with  the  acromion  process.  At  this  point 
they  are  curved  outward  on  the  flat,  on  an  angular  turn,  at  an  angle  of  forty-five 
degrees  or  more,  and  run  upward  and  outward  to  a  point  just  behind  the  anterior 
border  of  the  trapezius.  In  this  upper  part  they  are  curved  to  fit  the  contour  of 
the  shoulders  and  should  lie  flat  against  the  skin  when  the  axillary  straps  are 
tightened. 

b.  The  uprights  at  their  lower  part  are  farther  from  each  other  than  they  are 
at  the  top.  At  the  bottom  their  outer  edges  should  be  separated  by  a  distance 
somewhat  less  than  the  distance  between  the  two  posterior  superior  spines.  At 
the  top  they  should  lie  over  the  transverse  processes.  They  are  made  of  No.  16 
gauge  sheet  steel,  five-eighths  of  an  inch  wide,  and  should  follow  the  outline  of  the 
back  in  general,  but  whatever  correction  is  desired  in  the  standing  position  is  to 
be  made  by  bending  the  uprights  to  fit  the  curve  of  the  back  in  a  corrected 
position  rather  than  in  the  faulty  position. 

c.  The  cross-bar  consists  of  a  piece  of  steel,  which  in  length  should  be  one 
inch  less  on  each  side  than  the  breadth  of  the  body  at  the  level  where  it  is  placed. 
It  is  riveted  transversely  to  the  uprights  at  a  point  just  below  the  posterior  fold 
of  the  axilla.  The  projecting  ends  beyond  the  bars  should  not  rest  on  the 
scapulas,  but,  if  necessary,  should  be  set  backward  by  an  angular  curve  to  clear 
the  scapulse.     These  are  made  of  the  same  material  as  the  uprights. 

Buckles  are  placed  on  the  ends  of  the  pelvic  band,  and   the   cross-bar  and 
axillary  straps  are  riveted  to  the  upper  ends  of  the  uprights,  one  on  each  side. 
14 


2IO  FAULTY    ATTITUDE 

The  brace  is  finished  by  being  covered  with  leather,  or  by  being  nickel-plated, 
with  leather  covering  to  the  front  of  the  brace.  The  brace  is  attached  to  the 
body  at  the  top  by  means  of  axillary  straps  and  below  by  means  of  a  broad  belt 
of  sheep-skin  or  cloth,  which  fits  the  abdomen  and  supports  the  lower  part  of  it. 

Such  a  brace  is  worn  continuously  between  exercise  periods  but 
not  during  the  night. 

Summary  of  the  Treatment  of  Round  Shotdders.-~F\ex\h\t  cases  are 
treated  by  gymnastics  like  postural  scoliosis;  a  corset-waist  or  brace 
may  be  necessary  to  maintain  a  correct  position  between  treatments. 

Resistant  cases  must  first  be  made  flexible — (a)  by  gymnastics;  {h) 
by  manual  stretching;  {c)  by  stretching  in  apparatus;  {d)  by  forcible 
correction,  after  which  the  problem  is  to  maintain  the  improved  posi- 
tion, just  as  in  cases  originally  flexible. 


INDEX 


Acquired  scoliosis,  102 

Age,  114 

Anatomy,  8,  26 

Arthritis  deformans,  105-126 

Articular  processes,  40 

Attitude,  faulty,  191 

normal,  191 ' 
Asymmetrical  exercises,  146 
Average  heights  and  weights,  table,  72 

Back,  surface  anatomy  of,  26 
Bone,  plasticity  of,  47 
Bony  rotation,  49 
Braces,  151 

Cervicodorsal  scoliosis,  66 
Cicatricial  scoliosis,  109 
Compound  scoliosis,.  67 
Congenital  scoliosis,  99,  124 
Corrective  jackets,  151-157 
Corsets,  151 
Creeping  exercises,  150 
Curves,  physiological,  1 1 

Diagnosis  of  round  shoulders,  204 

of  scoliosis,  1 24 
Diseases  of  the  extremities,  106 
Dorsal  scoliosis,  63 
Dorsolumbar  scoliosis,  65 
Double  curves,  50 

Elasticity  of  the  spine,  2 1 

Empyema,  108,  125 

Etiology  of  round  shoulders,  201 

of  scoliosis,  97 
Evolution  of  the  spine,  20 
Examination  for  scoliosis,  71 
Exercises,  asymmetrical,  146 

creeping,  150 

symmetrical,  140 


Flexion  of  the  spine,  30 
Forcible  correction,  157 
Frequency  of  scoliosis,  70,  112,  115 
Functional  scoliosis,  53 

Gymnastics,  130,  132 

Habit  scoliosis,  109 
Habitual  scoliosis,  61 
Heart  disease,  109 
History  of  scoliosis,  i 
Hyperextension  of  the  spine,  32 
Hysterical  scoliosis,  108 

Identification  of  vertebrae,  26 
Inclination  of  pelvis,  23 
Infantile  paralysis,  106,  125 
Intervertebral  discs,  10,  88 
Ischias  Scoliotica,  108 

Jackets,  removable,  172 

Kyphoscoliosis,  65 

Lateral  corrective  pressure,  points  for, 

28 
Lateral  flexion  of  spine,  32 
Ligaments  of  the  spine,  12,  88 
Lumbar  scoliosis,  62 

Mechanism  of  scoliosis,  43,  58 
Movements  of  the  spine,  29 

conclusions  of,  41 
Muscles  of  the  spine  and  thorax,  16, 
27,  89 

Nerve  supply,  18 
Nervous  diseases,  107 
Normal  attitude,  191 
examination  of,  73 


False  scoliosis,  53 
Faulty  attitude,  191 
Flat  back,  200 


Occupation  scoliosis,  109 
Occurrence  of  round  shoulders,  202 
of  scoliosis.  III 


212 


INDEX 


Operative  treatment,  187 
Organs,  internal,  pathology  of,  94 
Organic  scoliosis,  61 
Ossification  of  the  spine,  20 
Osteomalacia,  105 

Pain,  51 

Paral3'tic  scoliosis,  124 

Pathology  of  round  shoulders,  203 

of  scoliosis,  83 
Pelvic  inclination,  23 
Pelvis,  asymmetry  of,  92,  102 

obliquity  of,  102 
Photography  in  scoliosis,  79 
Physiological  curves,  11,  21 
Phthisis,  109 
Planes  of  the  body,  21 
Plaster  jackets,  corrective,  157 
Plasticity  of  bone,  47 
Points  for  lateral  corrective  pressure, 

28 
Postural  scoliosis,  53 
Prognosis  of  round  shoulders,  203 

of  scoliosis,  127 

Quadruped  scoliosis,  in 

Rachitic  scoliosis,  104,  124 
Record  of  scoliosis,  79 
Relation  to  school  life,  117 
Removable  jackets,  172 
Retrotorsion,  56 
Reverse  rotation,  56 
Rickets,  104-124 
Rotation,  bony,  49 
of  the  spine,  36 
Round  back,  197-199 

hollow  back,  197-199 
shoulders,  197 
diagnosis,  204 
etiology,  201 
occurrence,  202 
pathology,  203 
prognosis,  203 
treatment,  204 
upper  back,  200 

Sacro-iliac  articulation,  1 2 
Scoliosis,  acquired,  102 
cervicodorsal,  66 


Scoliosis,  compound,  67 

congenital,  99,  124 

description,  51 

dorsal,  63 

dorsolumbar,  65 

examination  for,  71 

false,  S3 

from  asymmetries,  102 

from  cicatrices,  109 

from  empyema,  108,  125 

from  heart  disease,  109 

from  malformations  of  vertebral 
column,  99 

from    malformations    of    scapula 
and  thorax,  loi 

functional,  53 

habit,  109 

habitual,  61 

history  of,  i 

hysterical,  108 

in  quadrupeds,  in 

lumbar,  62 

mechanism  of,  43,  58 

occupation,  109 

organic,  61 

paralytic,  106 

pathology  of,  83 

postural,  53 

prognosis,  127 

rachitic,  104,  124 

record  of,  79 

structural,  61-127 

symptoms,  51 

terminology,  52 

total,  53 

transitional,  57 

types  of,  48 
School  fatigue,  117 

furniture,  118 

life,  117 
Schulthess'  measuring  apparatus,  82 
Sex,  113 
Short  leg,  102 

Shoulder  girdle,  pathology,  92 
Side  bending  of  che  spine,  32 
Spastic  paralysis,  107 
Spinal  ligaments,  1 2 

movements,  29 

muscles,  16,  27 


INDEX 


213 


Sternum,  14,  92 

Stretching  of  spine,  passive,  154 
Structural  scoliosis,  51-127 
Surface  anatomy  of  back,  26 
Symmetrical  exercises,  140 
Symptoms  of  scoliosis,  51 

Terminology,  52 
Thorax,  13,  90 

anatomy  of,  8 

muscles  of,  16 

shape  and  boundaries  of,  15 
Torsion,  reasons  for,  38 
Torticollis,  102 
Total  scoliosis,  53-127 
Tracings  in  scoliosis,  81 
Transitional  scoliosis,  57 
Treatment  of  postural  scoliosis,  1 29 

of  round  shoulders,  204 

of  structural  scoliosis,  1 27-131 


Treatment,  operative,  187 
True  scoliosis,  61 
Tuberculosis  of  spine,  105-126 
Types  of  scoliosis,  48 

Unequal  hearing,  103 

vision,  104 
Upright  position,  defects  of,   44 

mechanics  of,  43 

Varieties  of  structural  scoliosis,  62 
Vertebrae,  changes  in,  85 

identification  of,  26 

pathological  affection  of,  104 
Vertebral  column,  anatomy  of,  8 

Wolf's  law,  47  . 
Writing  position,  119 

X-ray  in  scoliosis,  77 


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